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R 0 TE 02 IS 2 G E Y! R E AC DA R O T

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VOLUME 7/ISSUE 2 - JANUARY 2020

EVERYONE IS A MASTERPIECE

LOVED BY PRESS

LOVED BY PRACTITIONERS

Alice Hart-Davis

Dr Tracy Mountford

“I am a real fan of Profhilo. I’ve seen and felt the way it improves the condition of my skin from the inside out.”

“An icing on the cake treatment - all our injectors love Profhilo and have it themselves - it’s a winner.”

Founder of The Tweakment Guide

Founder of The Cosmetic Skin Clinic

Children and Aesthetics CPD 19-310 185x192mm Front Cover EB.indd 1

Dr Nestor Demosthenous explores appropriateness of treating under 18s

Special Feature: Wellness and Aesthetics How and why practitioners introduce wellness into clinics

LOVED BY PATIENTS

Diet and Skin Health

Dermatology nurse Emma Coleman explains how diet can influence skin

“I had a Profhilo treatment. My face and neck are brilliant, such a difference. Everyone is commenting on how glowing my skin is.” H. A., Aged 47

03/12/2019 21:01 Tax Requirements

Accountant Samantha Senior advises on becoming self-employed


Contents • January 2020 06 News The latest product and industry news 12 On the Scene

Out and about in aesthetics

13 Advertorial: BELOTERO Volume Masterclass

Highlights from a Merz Institute of Advanced Aesthetics BELOTERO Volume Masterclass

15 Vivacy Stylage Cadaver Masterclass, Paris

Aesthetics reports on the highlights of the Laboratoires Vivacy Stylage Cadaver Masterclass in Paris

Special Feature: Incorporating Wellness into Practice Page 23

17 News Special: Innovation in Aesthetics

The most innovative products recognised at the Aesthetics Awards

20 Advertorial: Meet the Trainer Dr Gurnam Virdi tells Aesthetics about training with Luminera

CLINICAL PRACTICE 23 Special Feature: Incorporating Wellness into Your Clinic Practitioners uncover how and why they introduce wellness into their clinics 29 CPD: Children and Aesthetic Treatment

Dr Nestor Demosthenous explores the motivations and appropriateness of treatment in under 18s

33 Diet and Endocrine-induced Skin Conditions

Dermatology nurse Emma Coleman explains how diet can influence skin

41 Understanding Collagen-stimulating Dermal Fillers

Dr Ian Strawford details the use of collagen-stimulating fillers and shares a successful case study

45 Considering Antibiotic Resistance in Aesthetics

Prescribing pharmacist Gemma Fromage explores how practitioners can help slow antibiotic resistance rates

49 Advertorial: Profhilo Body Protocols

The use of multi-level dynamic bioremodelling on the body with Profhilo

51 Practising Hypnotherapy in Aesthetics

Dr Kathleen Long explores the use of hypnosis for needle phobia and pain

55 Case Study: Treating Acne and Hyperpigmentation

Dr Simi Adedeji treats a patient’s concerns while factoring in a budget

60 Advertorial: The Secret to Beautiful Lips Sharon Bennett advises how to enhance lips using Restylane Kysse 61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 63 Understanding Tax Requirements

Accountant Samantha Senior advises on becoming self-employed and registering for tax

66 Patient Educational Events Aesthetics speaks to Miss Sherina Balaratnam about how to organise a

In Practice: Understanding Tax Requirements Page 63

Clinical Contributors Dr Nestor Demosthenous is an international speaker and published author in the specialty. Dr Demosthenous has been an advisory board member for Allergan’s complications group 2015, and Healthcare Improvement Scotland Phase I (2016-7) & II (2017-8). Emma Coleman is an aesthetic and dermatology nurse practitioner with award-winning clinics across London and Kent. She is passionate about taking a holistic approach to skin ageing and dermatology. Gemma Fromage is a prescribing pharmacist and received her Master’s in Pharmacy in 2006. She started working in the aesthetics industry in 2010 and now runs her own clinic, Your Skin Health, in Raynes Park. Dr Ian Strawford is a GP and aesthetic doctor with more than 30 years’ experience. He is the medical director of Skin Excellence Clinics with clinics in Devon and Somerset. He is a trainer and KOL for Sinclair Pharma. Dr Kathleen Long qualified in 1976 and currently works as a locum GP and aesthetic practitioner. She is the president of the British Medical and Dental Hypnosis Society (Scotland). Dr Long is on the board of directors for BCAM. Dr Simi Adedeji graduated from Imperial College London with a Bachelor of Medicine, Bachelor of Surgery and Bachelor of Science. She is a former surgeon, working now as a GP partner and aesthetic practitioner.

patient educational event

69 Generating Patient Loyalty Dr Qian Xu explores the importance of patient loyalty and how to achieve it 73 In Profile: Miss Mayoni Gooneratne Miss Mayoni Gooneratne reflects on her career and shares why wellness is a

fundamental part of her practice

74 The Last Word Mr Benji Dhillon argues the pros and cons of charging for a consultation NEXT MONTH > IN FOCUS: Dermatology • Neck rejuvenation • Ageing and pigmentation • Understanding moisturisers

13 & 14 MARCH 2020 / LONDON

ACE 2020 REGISTRATION OPEN! 13th-14th March

The Aesthetics Conference and Exhibition www.aestheticsconference.com Use code: 10101


Delivering a trusted service for your medical aesthetic and clinic supplies.

Education Series Part 1 - Discolouration

Save the date Monday 3rd February

Leeds

Contact training@churchpharmacy.co.uk for more information

The new way to

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Editor’s letter Happy New Year everyone! I hope you’re all feeling refreshed after the Christmas break and are ready to embark on another exciting year in medical aesthetics. 2019 ended on a high at the Aesthetics Awards – what an amazing evening! It was Chloé Gronow my first one as Editor and a real honour Editor & Content to welcome everyone to the event and, in Manager particular, present the trophy for Outstanding Achievement in Medical Aesthetics to Dr Martyn King. Many of you will know Dr King as a founder of the Aesthetic Complications Expert (ACE) Group, which is a key source of evidence-based guidance on the prevention and management of complications. As well as his notable work for the ACE Group, we spoke to a number of Dr King’s peers who praised his mentorship and dedication to improving the specialty as a whole. With some secretive help from Dr King’s wife, nurse prescriber Sharon King, we managed to pull off a fantastic surprise that went down extremely well on the night! You can read more about Dr King’s achievements and all our Aesthetics Awards

winners in the special supplement you received with this issue. One of the biggest trends in recent years has definitely been wellness. The Global Wellness Institute estimates that the industry was worth $4.5 trillion in 2018 and is growing at rapid speed. Anecdotally, we have seen many practitioners incorporating wellness services into their clinics, claiming positive results from both patient satisfaction and business perspectives. But how do you introduce this service to your clinic? And what exactly should you be offering? Four practitioners share their experience and advice on p.23. Continuing the theme, aesthetic nurse Emma Coleman explores the impact of diet on skin health and how good nutrition can improve wellness on p.33, while prescribing pharmacist Gemma Fromage talks antibiotic resistance and its impact on aesthetic wellness on p.45. Finally, our In Profile interviewee, surgeon and aesthetic practitioner Miss Mayoni Gooneratne shares how she focuses on enhancing female wellbeing in her clinic. She discusses the impact pregnancy in particular can have on women’s wellness and advises what aesthetic practitioners can do to improve it through the treatments and support they offer. Turn to p.73 to read her thoughts!

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer for botulinum toxin and dermal fillers.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multi-award winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University.

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EDITORIAL Chloé Gronow Editor & Content Manager T: 0203 196 4350 | M: 07788 712 615 chloe@aestheticsjournal.com Shannon Kilgariff Deputy Editor T: 0203 196 4351 M: 07557 359 257 shannon@aestheticsjournal.com ADVERTISING & SPONSORSHIP Courtney Baldwin • Event Manager T: 0203 196 4300 | M: 07818 118 741 courtney.baldwin@easyfairs.com Judith Nowell • Business Development Manager T: 0203 196 4352 | M: 07494 179535 judith@aestheticsjournal.com Chloe Carville • Sales Executive T: 0203 196 4367 | chloe.carville@aestheticsjournal.com

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© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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LED

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Injectables Dr Sepideh Etemad-Shahidi @drsepi Thank you again @vivacylab.uk @terinavivacy for this incredible opportunity! We had so much fun furthering our horizons and education with the best surgeons on the cadaver course! Can’t wait for the next one! #Celebration Emma Bracey-Wright @emmabwlondon What a night! The incredible @drsophieshotter won Best Clinic South for @illuminateskinclinic I am so proud. #AestheticsAwards2019 #Celebration #Winner #SkinHealth Dr Stefanie Williams @drstefaniew Teaching at our last educational patient event, this time on hair loss. Hair is of course part of our largest organ, the skin, and therefore is part of dermatology! #Dermatology #Teaching #Aesthetics Julie Scott @facial_aesthetics A huge thank you to Dalvi Humzah Aesthetic Training and Simon Ravichandran. This photo is from Saturday at the #Radiesse Masterclass by #Merz Aesthetics, where I was lucky to be trained by such experts. #Learning #Trainer Dr Victoria Manning @drvix.manning A great day @cosmeticcourses accrediting new trainers to the @sinclair_uk @silhouette_soft team. Now homeward bound! #KOL #CollagenStimulation #Announcement Mr Dalvi Humzah @d_h_aesthetic_training We are very happy to welcome our new assistant tutor Mr Billy Leung. Billy has a passion for teaching anatomy, in particular, the head and neck. We look forward to Billy joining the team. #NewTutor #Anatomy

AestheticSource partners with LED company LightStim Aesthetic distributor AestheticSource will be supplying professional and at-home LED devices and beds, following its partnership with device manufacturer LightStim. “We wanted to offer practitioners an LED therapy device that they can trust and see visible results with,” said CEO of AestheticSource Lorna McDonnell Bowes. She added, “There is an abundance of LED therapy devices on the market right now so we have sought, and are now bringing to the UK market, the FDAcleared US brand, LightStim.” The two devices that the company will be distributing are the LightStim handheld LED therapy device, which is designed to target wrinkles by placing the light gently on the face for three minutes before moving on to the next area and repeating, and the LightStim LED Bed, a treatment that promotes totally body wellness and physiological function by utilising the company’s MultiWave patented technology. To support this, Crystal McElroy has joined the AestheticSource family as a LightStim business consultant. She has more than two decades’ experience in cross-functional roles including training, marketing and sales. McElroy will be offering support to new and existing LightStim customers, as well as organising training and events. ACE 2020

Enhance Insurance confirmed as ACE Business Track sponsor Enhance Insurance will sponsor the Business Track agenda taking place at the Aesthetics Conference and Exhibition (ACE) 2020 on March 13 and 14. The 19 free Business Track sessions are designed to aid those working in the specialty with sound business advice that will help them to successfully establish a private practice and stand out from the crowd. Topics covered within these 30-minute sessions include advice on marketing, PR, digital development, VAT and more. Director of Enhance Insurance, Martin Swann, said, “We, at Enhance, think that ACE is a fantastic event. The Business Track is a great forum for practitioners, clinic managers, and others within aesthetics to obtain some valuable information outside of their technical clinical skills to improve the running of their business.” He added, “We will also be presenting two sessions at the Business Track to give delegates some useful insight into those risks and exposures that can affect their business and valuable tips on how to mitigate these risks. We are really looking forward to attending next year’s conference to meet and connect with existing and potential clients.”

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Anniversary

Allergan celebrates 30 years of Botox In December, global pharmaceutical company Allergan celebrated the beginning of the 30th anniversary celebration for Botox with the ringing of the New York Stock Exchange opening bell. During the past 30 years, more than 100 million vials of Botox and Botox Cosmetic have been manufactured worldwide for various therapeutic and aesthetic uses. With two additional US Food and Drug Administration (FDA) approvals in 2019 for therapeutic indications of paediatric upper limb spasticity and lower limb spasticity, excluding spasticity caused by cerebral palsy, Botox and Botox Cosmetic now hold 14 therapeutic and aesthetic indications combined, Allergan confirms. “This incredible milestone underscores our constant focus on innovation and motivates us to further build on our 30 years’ of research and development efforts for Botox,” said Dr Mitchell Brin, senior vice president global drug development, chief scientific officer of Botox and neurotoxins at Allergan.

Vital Statistics Over the last year, the most Google searched plastic surgery in the UK was hair transplantation followed by liposuction then breast reduction (Flawless.org, 2019)

In a survey of 2,003 respondents, 76% of women said that they feel more confident on a good skin day and 61% suffer from ‘compare and despair’ syndrome (Foreo, 2019)

Digital

HA-Derma introduces Profhilo consumer website Exclusive distributor of the IBSA portfolio in the UK and Ireland, HA-Derma has launched a new Profhilo consumer-facing website, www.profhilo.co.uk. The company explains that the website was developed in response to demand from consumers seeking further information about the injectable Profhilo, as well as how to locate qualified practitioners offering the treatment in their area. HA-Derma director Iveta Vinklerova said, “The aim of this site is to serve as a first port of call for educating patients, as well as providing a route to locate and identify trained Profhilo practitioners to book a treatment,” she said. The website also contains treatment reviews from patients, media testimonials and press coverage, as well as product information about the treatment and Profhilo Haenkenium cream. Consumers can enter a postcode to access a list of practitioners that have been trained by an authorised HA-Derma trainer. Industry

Sinclair and Cosmetic Courses form partnership Aesthetic training provider Cosmetic Courses will run introductory training in Silhouette Soft sutures as part of an agreement with pharmaceutical company Sinclair Pharma. The company explains that the course is designed to give delegates all the prerequisite skills to reposition the tissues in the mid and lower face with the sutures and is open to experienced aesthetic doctors, dentists and nurses. All courses will be run at Cosmetic Courses’ newly CQC-registered training facility in Princes Risborough, Buckinghamshire, by nurse prescriber Mel Recchia and aesthetic practitioner Dr Fiona Durban. The first two courses are scheduled for February 3 and 23.

Since 2014, there has been year on year growth on the average amount of time per day spent using the internet via mobile phones. Most recently, 2018 saw a 23% increase and 2019 saw a 4.3% rise

(Hootsuite Digital Report, 2019)

54% of women worldwide consider under-eye bags as a top concern, whilst for 36% it is wrinkles around the eyes (Allergan 360 Report, 2019)

The market value for the beauty and personal care industry reached around £14.7 billion as of 2019 and is expected to grow to over £15 billion in 2020 (Statista, 2019)

Across Europe last year there were 724.7 million internet users and 462.5 million active social media users

(Hootsuite Digital Report, 2019)

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Events Diary 30th January - 1st February 2020 IMCAS World Congress www.imcas.com/en 5th-7th May 2020 British Medical Laser Association Conference www.bmla.co.uk 19th May 2020 British Association of Sclerotherapy (BAS) Conference www.bassclerotherapy.com/events

13 & 14 MARCH 2020 / LONDON

13th-14th March

The Aesthetics Conference and Exhibition www.aestheticsconference.com

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Hair

Aesthetics Editor Chloé Gronow to speak at Business of Hair seminar Aesthetics journal editor Chloé Gronow will be speaking at the second Business of Hair seminar, organised by DSL Consulting, taking place at the Crown Plaza in Solihull, Birmingham on January 18. The event was originally set for September 28 but was postponed to January. Joining Gronow at the event will be website, marketing and social media professional Mark Bugg, trichologist Eva Proudman, hair surgeon Dr Edward Ball, managing director at hair wholesaler Farjo, Saks Janan Farjo, and editor Vicky Eldridge. The seminar will provide hair restoration professionals with business content, covering techniques and top tips for building an effective website, using social media, basic marketing skills, GDPR, insurance, and how to incorporate a CRM system into a business. Gronow said, “I am delighted to be taking part in this innovative event. It will be great to meet hair surgeons and talk to them about how to improve their writing and reach relevant audiences. I hope to offer some valuable insight into how to boost practitioners’ profiles within the industry.” Body treatment

1 -2 October CCR www.ccrlondon.com st

nd

Topicals

Medik8 launches in-clinic skincare programme

UK skincare manufacturer Medik8 has launched a new 12-week programme of six in-clinic peels tailored to specific concerns, called 12 Weeks to WOW. This, the company states, should be combined with a prescribed at-home regime of its vitamin C, sunscreen and vitamin A products. Patients begin the journey with a pre-peel consultation where they will receive products to prepare the skin. Over the six peel treatments, practitioners have a choice of nine peels to treat skin concerns, which can be increased in strength and layered for maximum results. The final appointment, called the WOW Reveal, is where patients will be able to measure their results by comparing photos taken in their first consultation. In order to maintain results, a Medik8 Lifestyle Programme will then be advised.

Celluma releases full-coverage light therapy panel Light emitting diode (LED) device manufacturer Celluma has added two new products to its portfolio; the DELUX and DELUX XL. The company explains that the new additions are flexible, full-coverage light therapy panels designed to be used over the whole body. Incorporating blue, red and near-infrared wavelengths, aesthetic practitioners can expand services with the device which may be used to treat body acne, manage a variety of musculoskeletal conditions including joint pain and stiffness, arthritic pain, muscle tension and spasm. As well as this, it may also be used to decrease inflammation and increase micro-circulation to benefit many pain and skin-related conditions. The two sizes measure 57in x 24in and 65in x 30in, respectively. Celluma is FDA-cleared for skin and pain conditions and has received a medical CE mark for skin, pain and wound healing. Loyalty

5 Squirrels introduces loyalty scheme Private label cosmeceutical supplier 5 Squirrels has introduced The Tufty Nut card scheme to allow healthcare professionals to earn complementary marketing materials with every order placed. The company, which won the Best Clinic Support Partner accolade at 2019’s Aesthetics Awards, explains that the additional support tool aims to help customers get the most from launching their own brand skincare. Customers will receive a platinum nut with every order, which is exchangeable for personalised marketing tools, including standees, roll-up banners, skincare shelving units and much more. Gary Conroy, 5 Squirrels company director, said, “With retail space becoming an ever more competitive environment, our loyalty rewards will ensure clinics who work with 5 Squirrels will stand out from the crowd.”

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Energy

ULTRAcel Q+ HIFU device launches Medical systems distributer, SmartMed, a subsidiary of Healthxchange Group, has added the ULTRAcel Q+ device to its product portfolio. The non-surgical treatment designed to tighten and lift areas of the face and body uses high intensity focused ultrasound (HIFU) to stimulate new collagen growth and tighten the SMAS layer which alternatively can only be treated with surgery, the company explains. The device features a linear-shot HIFU treatment, allowing 300 shots in less than three minutes, as well as cartridges for small and wider treatment areas. SmartMed states that whilst some patients may see some initial effect, the full result will take place over two to six months as the body regenerates new collagen. Launch events, including the UK’s first live demonstrations of ULTRAcel Q+ will take place in London and Manchester early this year. Those wishing to attend are advised to get in touch with Healthxchange as spaces are limited. Pigmentation

mesoestetic releases intimate depigmentation treatment Pharmaceutical company mesoestetic has introduced dermamelan intimate to the UK market to address patient concerns surrounding pigmentation in the genital-perianal area, inner thighs and groin. The two-phase treatment includes the application of four products in clinic: dermamelan intimate peeling, post-peel neutralizing spray, dermamelan intimate mask and dermamelan intimate occlusive film. The patient is then given post-procedure crystal fiber intimate mask and dermamelan intimate home depigmenting gel cream to use out of clinic. A multicenter clinical study of 25 women between 27-50 years with hyperpigmentation in the intimate area evidenced reduction of pigmentation in different phototypes in all patients treated. Results were visible in a single clinical session. Dr Fernando Galcerán, who has been using the product, said, “The release of dermamelan intimate from mesoestetic has sparked a revolution in the treatment of pigmentation in intimate areas. I have now treated many patients with dermamelan intimate which has proven to offer a minimally invasive and effective answer to this concern. I have found there to be an immediate response to the treatment with the pigment lifting quickly and continual improvement using the homecare product.” mesoestetic is distributed in the UK by Wellness Trading. Muscles

Cutera launches truSculpt flex Laser and light-based medical provider Cutera Medical Ltd has launched a muscle sculpting device called truScuplt flex, which offers personalised treatments based on patient fitness level and shape. The device features multi-directional stimulation (MDS) which offers three treatment modes; prep, tone and sculpt. The prep mode creates a twisting motion that aims to warm up and stretch the muscles to slowly build a tolerance to muscle contractions, the tone mode contracts the muscles to increase strength and enhancement, whilst the sculpt mode is fast, deep, sequential contractions that aim to build muscle mass and increase the basal metabolic rate. Cutera explains that the device can treat up to eight areas simultaneously which, in turn, delivers high return on investment and patient satisfaction.

60

Agostina Murgia, partnership manager for Skinade, London How has the approach to patient care changed over time? I have been working in the medical sector for many years and have seen a greater appreciation from medical practitioners for products other than conventionally prescribed pharmaceuticals. They are also aware that their patients are concerned about appearance and are striving to ensure the best outcomes with minimal negative impact. Nutraceuticals have become an integral part of their approach, which was not the case just a few years ago. What role do nutraceuticals play in aesthetics? Nutraceuticals provide treatments, solutions and enhancements to general wellbeing in their own right and are also an incredible support for other treatments and procedures. For example, the reduction of down time for post-op patients has been remarkable. From preparing the patient for certain procedures to ensuring rapid and complete healing, the power and importance of nutraceuticals cannot be overestimated. How competitive is the nutraceutical market? It can appear to be competitive if one simply looks at the sheer number of products available, all promising very similar results. However, when you look at reliability, consistency and market position, few actually achieve what they claim. Practitioners have to give the best product of its type to their patients that will work, so this is what I ensure happens. What about the future? Skinade is at the forefront of this market, constantly researching, trialling and creating. We recently launched four new products that target specific problem areas and issues that our clients have highlighted. We only use sustainable natural ingredients and our formulae ensure maximum absorption and efficacy whilst striving for a well-balanced taste. Whilst Skinade cannot turn back time, I think it is key to an overall healthy body and mind and a real investment for your patients.

This column is written and supported by

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Recruitment


Vivacy hires new sales representative 
 13 & 14 MARCH 2020 / LONDON

T WO MONT HS UNTI L ACE 2 02 0 Al l S ES S I ON S F RE E TO AT TE N D

French injectable manufacturer Laboratoires Vivacy has welcomed Lauren Daley to the team as its new product specialist for the North West of England. Daley has been in the industry for five years and will support Vivacy national sales manager Terina Denny on promoting and selling Stylage, Desirial and Vivacy skincare products. Country director of Vivacy UK, Camille Nadal, said, “I’m delighted to welcome Lauren to the team! I believe she will do a great job covering the North of England as she comes with many years of experience.” Wellness

This year on 13 & 14 March, the Aesthetics Conference and Exhibition (ACE) 2020 will be showcasing a completely free agenda over the two days. Learn from Galderma, Teoxane, Allergan, Church Pharmacy, SkinCeuticals, HA-Derma, VIVACY Laboratoires, Celluma and many more! The sessions will be brought to you by leading aesthetic practitioners, discussing content exclusive to ACE. The educational workshops will also offer valuable advice and guidance on everything you need to know to grow your aesthetic practice. You can attend the sessions that suit your learning needs most, whether that involves laser treatments, injectable procedures, body contouring methods or skincare approaches. Every session at ACE is worth CPD points; you gain at least 1 per hour of learning!

FREE E XHIBITIO N & NET WORK I NG O P P O RTU N ITIE S As an ACE 2020 delegate, there are multiple opportunities to meet with over 80 of the top suppliers within aesthetics. Whether you’re looking for your next energy device, injectable product or skincare range, the packed 2,500m2 Exhibition Floor will have you covered! By attending ACE, you will also be able to liaise with leading service providers, offering support with insurance, finance, marketing and PR, as well as staying on top of the latest products, devices and suppliers on the market.

REGI S TE R F RE E TO DAY Us e code 1 01 0 1 A ES T HET I CSCO N F E RE N C E .CO M Access restrictions apply. See individual session descriptions for more information. HEADLINE SPONSOR

Mental health workshop to take place for practitioners Care Quality Commission registration service Inspire to Outstand is hosting a mental health awareness workshop for aesthetic practitioners on January 26 at The Pinnacle Rooms in Chester. Mental health senior lecturer from the University of Manchester Marcus Percy will explain to delegates what mental health, body dysmorphia, the Mental Health Act and Mental Capacity Act mean in aesthetic medicine, supported by a variety of case studies. Director of Inspire to Outstand Tracey Jones said, “The Mental Capacity Act helps to safeguard the human rights of people aged 16 and over who lack mental capacity to make decisions. This is an important area for those working in aesthetic medicine and one which the healthcare regulator will expect to see both governance, guidance and practitioner education. Teams need to be able to identify situations where the Mental Capacity Act may be relevant and know what steps to take to maximise and assess a person’s capacity especially when making decisions to embark on cosmetic treatments.” Carboxytherapy

Cosmo Pro releases new CO2 device Aesthetic distributor and manufacturer Cosmo Pro has launched the DIOX carboxytherapy system. Cosmo Pro explains that the carbon dioxide (CO2) therapy utilises patent technology for the micro-injection of CO2 that can be used to treat skin laxity, cellulite, acne, scars and varicose veins, as well as other common concerns. The DIOX system features a touch-screen interface and both automatic and manual modes. The company adds that the heat system also minimises discomfort via specialised software with digital sensors, which filters the precise control of CO2.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Skincare

ZO Skin Health launches Firming Serum Aesthetic skincare provider ZO Skin Health has introduced the Firming Serum as part of its range. The company explains that it is formulated to improve the overall appearance of the complexion, combat sagging and visibly improve skin laxity for a more defined facial contour. The Firming Serum uses a bioactive formula which aims to support the structural integrity of the skin, including sodium DNA to work alongside the skin’s matrix formation process to support fibroblast activity. It also includes ZCORE, which consists of biomimetic tetrapeptide and sweet yellow clover, supporting the anchoring fibrils for dermal-epidermal junction integrity, ZO Skin Health explains. Topical

Chemical peel for vaginal rejuvenation released A chemical peel aimed at improving the external appearance of the vagina has been launched into the UK, called the Pink Intimate System. The peel is distributed exclusively by aesthetic product and equipment company Trimedica. The company explains that the system is designed to restore a more youthful, healthy appearance to the vaginal and sensitive-area tissues, as well as tighten, lift and whiten skin. The formula includes ingredients such as vitamin B12, bisabolol, ionic acid, amongst others. According to the company, it can be used on the mons venus, labia majora, perianal region and the inguinal region, as well as other areas of the body including the underarms, elbows, knees, glutes and areola. A 2017 study saw 40 female subjects aged 40-71 apply the topical to an intimate area for one 10-15 minute session per week for four to five weeks. All subjects returned to their normal daily activities immediately after sessions without any discomfort. No case of intolerability was recorded. According to the subjective self-evaluation, the appearance of the intimate areas of the body showed significant improvement in all 40 subjects. Aesthetic practitioner Dr Kannan Athreya, who has been using the product said, “The Pink Intimate treatment may be used to help condition and treat other body areas where skin rejuvenation and/or pigment lightening may be desired and as such, the versatility, cost effectiveness and demonstrable outcomes make the Pink Intimate a compelling product to add to your treatment skillset.” Industry

Cynosure sold for $205 million Medical technology company Hologic has entered into a definitive agreement to sell its Cynosure medical aesthetics business to an affiliate of investment funds managed by Clayton, Dubilier & Rice for US $205 million. This is subject to regulatory approvals and other conditions. Under the agreement terms, approximately 825 employees will transfer with the Cynosure business. “We are excited about the future for Cynosure with this recent announcement,” said Erik Anderson, division president of Cynosure. He added, “Our business was strengthened under Hologic, and this new acquisition will accelerate our growth via expanded sales and marketing efforts along with further investments in innovation and new products which will support our customer partners and improve clinical outcomes for consumers.”

BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

AESTHETICS AWARDS First of all, the BACN would like to congratulate all the BACN members who were Finalists, Commended, Highly Commended and won at the Aesthetics Awards held in December. The stand out for us was honorary member Jackie Partridge, who won the SpringPharm Award for Aesthetic Nurse Practitioner of the Year, with some great competition from other fantastic BACN members. It really was a brilliant night celebrating the very best in aesthetics, and it was fantastic to see so many nurses succeed.

BACN MEMBERSHIP SURVEY Each year, the BACN sends a thorough survey of questions relating to aesthetic practice in nursing to all BACN members. The information gathered allows for membership services and offers to be amended and tailored specifically to the responses and changing trends. This year, the BACN is asking more questions regarding prescribing, complications and product trends. BACN members will be contacted throughout January and the closing date for responses will be January 31 – with the results published in February. For more information about the survey, please contact Gareth Lewis, BACN Membership and Marketing Manager at glewis@bacn.org.uk.

2020 Throughout 2020, there are a number of BACN activities and initiatives for members to look out for, including the ‘I AM A BACN NURSE’ campaign, showcasing the incredible achievements of BACN members and the commitment to patient safety within aesthetics. Other programmes are the Aesthetic Nursing Speciality Framework, which we aim to launch later in 2020. This year, the BACN regional meetings will be structured to support both newer nurses in aesthetics and also offer educational content and networking opportunities for more experienced BACN members, which we believe will be really beneficial. 2020 will be an exciting year to be a BACN member, and with support from partners in aesthetics, we’re hoping there will be more on offer for members than ever before! #BeBACN This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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On the Scene

Cynosure and iS Clinical Aesthetic Exchange, London A two-day symposium called the Aesthetic Exchange was held at King’s Fund in London by laser manufacturer Cynosure, in collaboration with cosmeceutical brand iS Clinical. Delegates attended the event on November 22-23 to learn about the latest developments in lasers, as well as how to maximise patient success for the face and body by integrating medical-grade skincare. The keynote speakers included US cosmetic laser surgeon Dr Dianne Quibell, iS Clinical director Dr Charlene DeHaven and UK surgeon and aesthetic practitioner Miss Sherina Balaratnam. The first day focused on the face. The science and evolution of laser and light-based technologies were discussed, as well as epigenetics and the power of cosmeceuticals, creating a progressive patient journey, pigmentation and vascular issues, scarring, rejuvenation, and other topics. The following day focused on the body, and included talks by Dr Quibell on new developments to the SculpSure machine, called SculpSure 2.0, which is coming to the UK soon. Following the event, Cynosure country manager for UK and Ireland Ben Savigar-Jones said, “Following the huge success of our previous Aesthetic Exchange event, we saw that as a good sign that we needed to do it again, so decided to scale it up and make it even bigger with some international speakers. It’s been fantastic to combine two companies that have the science and research background to allows us to get maximum patient outcomes.” On the Scene

Aesthetics Awards 2019, London On December 7 more than 700 aesthetic practitioners, clinics, suppliers, training providers, and other industry companies attended the dazzling Aesthetics Awards 2019. Hosted at the Park Plaza Westminster Bridge hotel, the evening celebrated achievements of the past year recognising Winners, Highly Commended and Commended finalists in 26 categories. Guests were welcomed to the ceremony by editor and content manager Chloé Gronow which was then followed by a well-received 15-minute set from comedian Tom Allen and a delicious three-course meal. Aesthetic practitioner and award winner Dr Nestor Demosthenous commented, “Tom Allen is by far the funniest comedian we have seen over the last five years of attending.” He added, “The food and its presentation was also the best it’s been so far. It gets better and better each year!” After this, the Awards were presented, and celebrations were well underway. Amongst the winners was Dr Martyn King, who won the Outstanding Achievement Award, Dr Jonquille Chantrey who picked up The John Bannon Award for Medical Aesthetic Practitioner of the Year and nurse prescriber Jackie Partridge who won The SpringPharm Award for Aesthetic Nurse Practitioner of the Year. Founder of the Black Skin Directory and winner of the The Clinetix Award for Professional Initiative of the Year Dija Ayodele said, “The Aesthetics Awards are a chance to see and celebrate with colleagues who’ve worked hard all year! It’s also an opportunity to network and build relationships going forward. It was great to see Chloé leading the charge and I though she did a wonderful job! The event was fabulous as always.” Entry to the Aesthetics Awards 2020 will open in May.

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News in Brief Teoxane appoints new country expert Swiss aesthetic manufacturer Teoxane has appointed aesthetic practitioner Dr Selena Langdon as its latest country expert. Emma Riley, assistant medical education manager at Teoxane said, “We are delighted to welcome Dr Langdon to the Teoxane UK Faculty as a country expert. She and Teoxane are very aligned in the importance of delivering high-quality, evidence based training. Dr Langdon has a wealth of knowledge and experience, which we are excited to see her share with our customers during training courses.” Intraline appoints KOLs Intraline Medical Aesthetics has confirmed that aesthetic practitioners Dr Simon Zokaie and Dr Mark Holmes will be key opinion leaders for its portfolio of medical aesthetic products. Dr Zokaie said, “I’m very pleased to be appointed as a KOL and help support Intraline medically in their product range. I find Intraline very genuine, honest and ethical. I know they share the same passion as me for education and knowledge.” Booking open for Tixel workshop AZTEC services, the UK supplier of rejuvenation system Tixel, will be hosting a UK workshop on June 4. The event will be held in Church House Westminster and will feature key opinion leaders including consultant aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai, dermatologist Dr Harryono Judodihardjo and aesthetic practitioners Dr Ian Strawford and Dr Ofir Artzi. It will cover a range of topics including the benefits of using Tixel, new protocols, panel discussions and a Q&A session. Acquisition Aesthetics announces Manchester training dates Training provider Acquisition Aesthetics has confirmed that two courses will return to Manchester on April 11 and 12. Doctors, dentists and nurses are eligible to attend. The company explains that the foundation botulinum toxin and dermal fillers course will take place on the Saturday and the advanced course will be on the Sunday. It will cover everything from business and marketing skills. anatomy, complications, consultation and consenting with handson practice on live model patients in small focused learning groups, Acquisition Aesthetics confirms.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Advertorial Merz Pharma UK Ltd

BELOTERO® Volume Masterclass with Emma Chan Highlights from a Merz Institute of Advanced Aesthetics BELOTERO® Volume Masterclass Aesthetic nurse prescriber Emma Chan helped delegates to become Merz Institute of Advanced Aesthetics certified practitioners at the latest Masterclass within the Merz Innovation Partner Programme. Delegates attended an exclusive, invitation only educational meeting on December 2nd. The goal of the Masterclass was to provide expert-led, scientific education on BELOTERO® Volume, supported by practical guidance of the bespoke injection technique. Delegates learnt how the unique CPM™ (Cohesive Polydensified Matrix) technology can be harnessed to deliver optimal natural results for patients.

Learning the science Emma began the Masterclass by delivering a scientific lecture on the rheology of volumising fillers and the differentiating features of BELOTERO® Volume. The Masterclass then moved on to cover a full facial analysis of a patient, combined with a deep dive into specific facial anatomy related to the treatment plan. Emma delivered a live demonstration of temples, cheeks, chin and jawline, showcasing a variety of specific multi-layer injection techniques bespoke to BELOTERO® Volume. Emma’s treatment plan focused on achieving holistic facial volumisation by creating natural transitions, projection and definition. The afternoon session was dedicated to the delegates gaining first-hand injection technique experience with BELOTERO® Volume. Each delegate had exclusive one-toone guidance time, where they received support in creating the appropriate mid face volumisation treatment plan for their own patient followed by supervision of their injection technique. Throughout the session, Emma offered expert advice and support to the delegates as they shared their own stories and experiences of aesthetic medicine. The day closed with a review of the objectives that were set at the start of the day and a summary of key learnings. Upon completion of this masterclass, each delegate earned 7 CPD points and became a Merz Institute of Advanced Aesthetics certified practitioner. General and cosmetic dentist Dr Natalie Ball said following the event, “My Merz Account Manager Kerry Lavin has been really informative throughout my journey from being invited to register for the Masterclass to identifying my needs and ensuring I was provided with the right educational opportunity for my own professional development with Merz brands.” Dr Ball said that Emma created a very informative, approachable and safe environment where delegates felt comfortable to ask questions. She added, “As well as

this, Emma’s thorough knowledge of Merz products and how to use them in all types of indications and patients has just been brilliant. I’ve been injecting for seven years, and I’ve been doing cheeks for five, but Emma has taught me how to use BELOTERO® Volume in a much more bespoke way for individual patient needs. It’s not one size fits all. Today we looked at all the patients in a novel way, incorporating other facial features into the cheek treatment. My treatment planning is definitely going to change going forward.”

Looking to learn in 2020? The Merz Institute of Advanced Aesthetics will be hosting more Masterclass days with its experienced Merz Innovation Partners. Get in touch with your Merz Account Manager to find out more.

Meet Merz Innovation Partner Emma Chan Emma Chan graduated from Lancaster University with a degree in Nursing Bsc (hons) in 2000. After gaining an MSc in Advanced Practice, Emma then chose the field of aesthetics to further her nursing journey. Since 2007, Emma’s passion for Emma Chan, this discipline, has seen her invest in her MSc BSc (Hons) NIP own professional development to build a reputation as an expert practitioner at her established aesthetic clinic in the north west of England. Emma also dedicates her professional time to sharing expertise and knowledge as a regional trainer.

Merz Pharma UK Ltd. 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire, WD6 3SR Phone: 0208 236 0000 Email: customerservices@merz.com M-BEL-UKI-0689 Date of Preparation December 2019 Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

Aesthetics | January 2020

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Vivacy Stylage Cadaver Masterclass, Paris Aesthetics reports on the highlights of the Laboratoires Vivacy Stylage Cadaver Masterclass in Paris On November 22, French injectable manufacturer Laboratoires Vivacy invited 40 aesthetic practitioners to the Fer à Moulin School of Surgery in Paris for live anatomy dissections and hands-on classes to help them learn about and avoid complications when administering facial injections. Upon arrival the evening before the masterclass, delegates enjoyed a French meal, networked and were introduced to the chairman of Vivacy, Waldemar Kita. In an interview with Aesthetics, Kita described the company’s strong commitment to teaching and anatomical training and said that he was thrilled to invite UK practitioners to Vivacy’s home country. Kita said, “After opening the Vivacy UK subsidiary in the UK just seven months ago, we are delighted to invite the first UK practitioners to Paris. It’s important that the practitioners using our products have the best practical and scientific training available and also understand the science behind how our products work alongside the anatomy.” The following morning, country director of Vivacy UK, Camille Nadal, welcomed and introduced delegates to the speakers of the day, which included scientific and medical director of Vivacy France, Denis Couchourel, face and neck cosmetic surgeon, Mr Philippe Kestemont, facial plastic surgeon Miss Cecile Winter, professor of plastic surgery, Professor Ali Mojallal, and plastic surgeon Mr Benjamin Ascher. In his talk, Couchourel explained the science behind crosslinking HA dermal fillers and how Stylage products are characterised by unique combinations of viscosity, elasticity and cohesivity. Couchourel used an interesting analogy to explain crosslinking; he said, “HA crosslinking is like spaghetti and cheese. The spaghetti represents the HA chains, which you can easily pick up, until you add cheese. Cheese is the crosslinker, which clings to the spaghetti making it all stick together.” Mr Kestemont then delivered a lecture on considerations for treating the mid-face, which was followed by Miss Winter who presented on the lips and perioral area. Professor Mojallal then discussed the lower face, illustrating how the ageing facial shape changes with time by showing several blurred images and getting the audience to guess how old they were. He also explained how the fat changes in the face with age, explaining that its behaviour is different in the mid-face than the lower face, which he later pointed out in his cadaver masterclass. Professor Mojallal then explained the importance of understanding the location of the facial ligaments, saying that filler must be placed in-between these landmarks. Presenters individually spoke about different anatomical considerations while dissecting the cadavers in front of the audience. In the afternoon, the 40 delegates were split into four workshop groups to closely observe the speakers perform live dissections while they provided anatomy explanations, as well as safety and injections tips. Delegates also had the opportunity to try new and different techniques using the Stylage products on the cadavers with the oversight of the teachers. Professor Mojallal led the nose dissection, Miss Winter explored the

lower face and neck, Dr Kestemont shared the upper face and labial region and Mr Ascher shared a powerpoint presentation and performed a dissection on the danger zones for volumising injections on the face and hands. The training had a great response from delegates and many said it was among the best education they have ever had. Aesthetic practitioner Dr Dev Patel said, “This was one of the most satisfying training days I have attended in recent years. The morning consisted of lectures from four renowned French plastic surgeons and anatomists and I hung on to their every word. I enjoyed a superb refresher of facial anatomy with a handful of priceless nuggets to take away and undoubtedly influence my aesthetic practice for the better.” Dr Patel added, “One key and interesting learning point was the difference in facial fat between the upper/mid-face and the lower face/neck, which explained a lot in regards to the visible differences we see with ageing in these two areas. My 24 hours in Paris – courtesy of the Vivacy team – will allow my injectable practice to be safer and perhaps lead to better aesthetic outcomes. An invaluable trip to the French capital!” Nadal said following the event, “We are thrilled that delegates have said that they have all learnt something new and that the training was to such a high standard. Training is so important to us at Vivacy and we invest a lot in it. It was very special to have our four anatomical experts here today, as they are so popular and well known in France that you can never get them in one place, so it was a real treat for delegates.” Mr Ascher added, “Today went very well and it was great to meet practitioners from the UK. There is nothing more important than anatomy knowledge when it comes to dermal filler and botulinum injections, not only for safety but also for best aesthetic outcomes. Anatomy training is at the forefront of international conferences such as the upcoming IMCAS on January 30-February 1, of which I am the founder of, and I am looking forward to teaching more delegates the importance of this crucial area in the future.” Nadal stated that Vivacy plans on inviting more practitioners to Paris and will continue to host education in the UK. The company is also investing in new product developments to address intimate area concerns for both men and women, which will be an exciting development, according to Kita.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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News Special Product Innovation

Innovation in Aesthetics An overview of the innovative products recognised at the Aesthetics Awards 2019

How do you determine innovation? What does innovation mean? Many know it as a new idea, design, product or the development of these.1 Aesthetics asked its Clinical Advisory Board, What does innovation mean to you? Clinical lead Mr Dalvi Humzah said, “Innovation in aesthetics is thinking and developing something out of the box that will improve either practitioners’

abilities or patients’ experiences.” Nurse prescriber Jackie Partridge added, “Innovation is vital for a company to succeed in any business, but research is just as important. The products and services we utilise in aesthetics must be backed by science, evidence and safety.” The DigitRx Award for Product Innovation of the Year had nine finalists at the Aesthetics Awards

on December 7. Each were launched in the UK after 1 January 2018. Upon examining the entries, judges assessed them for genuine innovation or product advancement, leading to treatment for new indications, quicker or easier treatments, better treatment outcomes and enhanced patient safety, all supported by sound evidence. Let’s see what products were recognised…

CELLUMA – WINNER What it is: A light therapy device that delivers blue, red and near-infrared light energy, simultaneously. It is FDA-cleared to treat facial wrinkles, acne, diminished local blood circulation, muscle and joint stiffness, muscle tissue tension, muscle and joint pain, muscle spasm, and arthritic pain. Before launching in the UK, Celluma gained a CE Mark as a Class IIa medical device for all its FDA-clearances, as well as dermal wound healing, in the EU. In a clinic trial using Celluma to treat facial wrinkles, 80% of participants reported that they experienced an improvement in skin texture, 77% reported an improvement in skin firmness and 66% reported an improvement in facial wrinkles after four weeks.2 More research available.3 What practitioners say: US oculofacial plastic surgeon Mr Costas Papageorgiou says, “Celluma is an integral component of my clinic’s signature treatments which employ the regenerative and lifting effects of multi-layered energy waves and technologies in single sessions. The biophotonic waves of Celluma are implemented as the final step to accelerate recovery by providing the cells with the energy to heal from within. Quite often, I recommend the device as an ongoing maintenance treatment at home to further optimise results.” Manufactured by: BioPhotas and distributed by Celluma UK

FACETITE – HIGHLY COMMENDED What it is: FaceTite is a handpiece delivering InMode’s proprietary Radio Frequency Assisted Lipolysis (RFAL) technology to the face and neck. Targeting a depth of 5-10mm, the treatment aims to influence fat contraction, not lipolysis, resulting in skin tightening and improvement of contour. Bipolar radiofrequency and dual temperature control aim to enhance the safety of these devices, which are FDA approved. One study of 55 patients, with a mean age of 51 years, indicated that 85% were satisfied with their contouring and skin tightening result. Two independent plastic surgeons considered the improvement in contouring and degree of skin tightening good to excellent in 52 of 55 cases.5 More data available.6,7 What practitioners say: Dublin-based cosmetic surgeon Mr Peter Prendergast says, “With FaceTite, I’m now able to offer patients a real alternative to surgery that produces visible results. The sophisticated technology employs precision heating in the subdermal tissues like no other device. No other treatment can give such impressive results in face and neck tightening with no scars, no drains and no general anaesthesia, allowing the patient to return to work in a few days. It’s dramatically enhanced my aesthetic medicine practice.” Manufactured and distributed by: InMode

EVERACTIVE C&E + PEPTIDE – COMMENDED What it is: A vitamin C and peptide serum aiming to reduce the visible signs of free radical damage and ageing for all skin types, including acne-prone skin, rosacea, pigmentation and ageing. To prevent L-ascorbic acid oxidisation in the bottle and to ensure it is optimally active, the product features a speciallyengineered cap, suspending the vitamin C crystals separately from the serum in order to protect it from air, light and water. The patient is the last person in the manufacturing process; only mixing the solution when they are ready to use it, ensuring 15% L-ascorbic acid is delivered to the skin. Product-specific in-clinic case studies and trials are well underway. Research is well-established for key ingredients L-ascorbic acid and Matrixyl synthe’6.8,9,10 What practitioners say: Aesthetic practitioner Dr Dev Patel says, “EverActive C&E + Peptide is a powerhouse formulation that I think is the most effective all-rounder I can offer to my patients. It contains the only bioavailable form of vitamin C for the skin at the ideal strength. Furthermore, you activate the vitamin C at home meaning even the last drop will be clinically effective.” Manufactured and distributed by: Alumier Labs

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Celltense Serum What it is: A serum that aims to increase efficacy for radiofrequency treatments for cellulite and skin tightening. It is most effective in treating mild to moderate cellulite and can be used on arms, abdomen, hips, buttocks and thighs. The product contains a new patented active ingredient – Gold Thioethylamino Hyaluronic Acid (nano) – gold nano particles linked with low molecular weight hyaluronic acid. A double-blind, randomised, placebo-controlled study with 24 participants using a combination of Celltense Serum and radiofrequency indicated 18.1% improvement to cellulite volume vs. 0.9% using radiofrequency alone, 17.5% echogenic density increase in the dermis vs. -3.3% using radiofrequency alone, and 90% of patients responded to the treatment vs. 55% using radiofrequency alone.11 More research available.12 What practitioners say: Laser specialist, KOL and trainer for Lumenis, Chantal Johnson, says, “We have found the results using Celltense Serum with our Lumenis NuEra Tight RF have exceeded our expectations. We are seeing the skin heat at an increased rate and it assists maintaining a constant temperature over a larger area with significant increased skin tightening and volume reduction, decreasing treatment times while taking our results to the next level with innovative science.” Manufactured and distributed by: Elenzia

Plasma Shower What it is: The Plasma Shower is a handpiece on the Plasma BT device, which creates an ionised stream of non-ablative cold plasma 25mm or 8mm wide. It aims to treat concerns like acne, ageing, wound healing, pigmentation and dull skin by removing bacteria and allowing for transepidermal delivery of products. Case studies have been published in the Aesthetics journal that showcase successful results using the Plasma Shower.15,16 What practitioners say: Dr Beatriz Molina says, “One of the biggest innovations yet. The Plasma Shower allows for transepidermal delivery of product without injections, so can be used instead of mesotherapy. I have also treated dermal filler complications, delivering hyaluronidase without a needle, which is incredible.” Manufactured and distributed by: Beamwave Technologies

skinbetter science Alto Defence Serum What it is: An antioxidant serum that can be used on all skin types, to help defend the skin against environmental stressors and oxidative stress as a result of pollution, blue light, UVA/UVB exposure and IR radiation. It also aims to enhance skin tone and luminosity, as well as reduce redness. A 12-week, singlecenter, clinical study demonstrated average improvements from baseline of 37% fine lines/wrinkles, 17% skin tone, 13% dyschromia, 18% erythema and 4% percent pores (N=21) with continued improvements at 16 weeks.17 More research available.18 What practitioners say: Dr Amiee Vyas says, “It has become the go-to antioxidant product in my practice. It’s lightweight elegant formulation makes it suitable for all skin types and ages. With 19 water-soluble, enzymatic, and lipid-soluble antioxidants, it provides comprehensive protection at all cellular levels of the skin and furthermore has become a firm favourite for my patients, who have previously experienced irritation with vitamin C preparations.” Manufactured by: skinbetter science; distributed by AestheticSource

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Sunekos What it is: Sunekos is an injectable treatment and Class III medical device that aims to reduce wrinkle severity, improve facial volume loss and increase hydration. The formula contains non-crosslinked hyaluronic acid to hydrate the skin, along with a patented formula of amino acids, which aim to induce collagen and elastin synthesis. It is available in two formulations: Sunekos 200, a low molecular hyaluronic acid weight for the natural regeneration of the dermal tissue and Sunekos 1200, a higher molecular HA weight for volumising that can be injected via needle or cannula. What practitioners say: Aesthetic nurse prescriber Sarah Edwards says, “Sunekos is the perfect addition to my treatment toolbox. Not only is it vegan friendly, it provides an alternative for my patients who do not wish to go down the traditional route of dermal fillers/toxin. I have found it particularly successful in treating dark eye circles and addressing static lines on the forehead.” Research: A study of 25 female subjects aged 48-65 indicated an improvement in facial volume loss (42.1%), reduction in wrinkle severity (22%), reduction in severity of crow’s feet (22.4%), increase in skin surface hydration (24.5%) and increase in deep skin hydration (9.9%) after six months.20 Manufactured by: Sunekos Laboratories and distributed by Med-fx

Soprano Titanium What it is: Soprano Titanium is a hair removal platform with a large 4cm2 spot size and advanced cooling system that aims for faster and pain-free treatments. It combines three laser wavelengths into a single applicator (755 nm, 810 nm, 1064 nm), simultaneously targeting different tissue depths and anatomical structures within the hair follicle. Product specific papers yet to be available; however research is available for technology used in the device.19 What practitioners say: Spanish practitioner Dr Pablo Naranjo says, “I am very pleased with the results I am able to achieve with the Soprano Titanium. Besides the high efficiency and safety record, which are the base for any hair removal treatment, there are additional features, such as Smart Clinic and the unique Quattro applicator, which set it above and beyond any other system on the market today.” Manufactured by: Alma Lasers and distributed by ABC Lasers

Medik8 r-Retinoate Intense What it is: This product features encapsulated retinyl retinoate and crystal-stabilised retinaldehyde together in one night-time formula. Medik8 has worldwide exclusivity on encapsulated retinyl retinoate and state it’s the company’s ‘greatest ever formulation’. Product specific papers yet to be available; however, there is much research on retinyl retinoate and retinaldehyde.13 What practitioners say: Skincare and laser specialist Debbie Thomas says, “I always use a vitamin A (retinol) product as I believe it’s the key to age management. I love Medik8’s r-Retinoate Intense. The formula is eight times more powerful than other retinols, but with less irritation.”14 Manufactured and distributed by: Medik8

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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WANT TO BE RECOGNISED FOR INNOVATION? Entries for the Aesthetics Awards 2020 will open on May 1. Eligible products must have launched into the UK market after 1 January 2019. Contact the team for more info: contact@aestheticsjournal.com REFERENCES 1. Cambridge Dictionary, ‘Innovation’, 2019. <https://dictionary.cambridge.org/dictionary/english/innovation> 2. Data on file with Celluma. 3. Ryan Spitler & Michael W. Berns, comparison of laser and diode sources for acceleration of in vitro wound healing by low-level light therapy, Journal of Biomedical Optics 19(3), 038001 (March 2014) 4. Jacob Haiavy, Innovation For Treatment Of Capsular Contracture. <https://dcd2fe06bf58808e48f5-f58c 1372aeba1bc7277f53e7c981d121.ssl.cf5.rackcdn.com/c2836c32cd2a48c18b4d253f5b0da0f3_CellumaInnovation-for-the-Treatment-of-Capsular-Contracture-Haiavy.pdf> 5. DH Ahn, et al., Non-Excisional Face and Neck Tightening Using a Novel Subdermal Radiofrequency Thermo-Coaugulative Device, Journal of Cosmetics, Dermatological Sciences and Applications, 2011. 6. E Keramidas, et al., Radiofrequency-assisted Liposuction for Neck and Lower Face Adipodermal Remodeling and Contouring, PRS Global Open, 2015. 7. M Divaris, et al., Face expressive lifting (FEL): an original surgical concept combined with bipolar radiofrequency, Eur J Plast Surg 2013. 8. Pumori Saokar Telang, Vitamin C in dermatology, Indian Dermatol Online J. 2013 Apr-Jun; 4(2): 143–146. 9. Juliet Pullar et al., The Roles of Vitamin C in Skin Health, Nutrients. 2017 Aug; 9(8): 866. 10. Matrixyl®synthe’6®, Literature, Croda, 2019. <https://www.crodapersonalcare.com/en-gb/products-andapplications/product-finder/product/3046/Matrixyl_1_synthe%E2%80%996#tab-collapse-literature> 11. Efficacy test of a serum with gold nanocomplex combined with radiofrequency to reduce the cellulite effects. Endor Technologies S.L., Instituto de Fotomedicina, Dr. Joaquin Querol, Gabriel Buendía

Bordera M. Sc., Dr. Jorge Gaviria, Dr. Juan Bascones. 2017. 12. Beatriz Molina, Case Study: Treating a NSR Complication, Aesthetics journal, 2017. <https:// aestheticsjournal.com/feature/case-study-treating-a-nsr-complication> 13. Medik8, Medik8 r-Retinoate Intense, Proof, <https://www.medik8.com/retinoate/youth-activating-creamintense#Proof> 14. Kim H, et al., Synthesis and in vitro biological activity of retinyl retinoate, a novel hybrid retinoid derivative, Bioorganic & Medicinal Chemistry, 06 May 2008, 16(12):6387-6393. 15. Beatriz Molina, Case Study: Treating a NSR Complication, Aesthetics journal, 2017. <https:// aestheticsjournal.com/feature/case-study-treating-a-nsr-complication> 16. Frances Turner Traill & Lyndsey Loughery, Case Study: Treating Hair Loss, Aesthetics, 2018. 17. David H. McDaniel et al., Evaluation of the Antioxidant Capacity and Protective Effects of a Comprehensive Topical Antioxidant Containing Water-soluble, Enzymatic, and Lipid-soluble Antioxidants, J Clin Aesthet Dermatol. 2019;12(4):46–53. <http://jcadonline.com/antioxidants-april-2019/> 18. David H. McDaniel, et al., Clinical Evaluation of a Comprehensive Topical Antioxidant in Subjects with Mild to Moderate Photodamaged Skin, JAAD, September 2018, Volume 79, Issue 3, Supplement 1, Page AB77 19. Soprano Titanium, Clinical Research, Alma Lasers. <https://www.alma-soprano.com/clinical-research/ 20. Sparavigna A & Orlandini A, ‘Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino Acids: A Monocentric Six-Month Open Label Evaluation, The Journal of Clinical Trials, July 12, 2017.

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Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


Advertorial Luminera

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Tell us about the Luminera range… There are four hyaluronic acid (HA)-based fillers in the Hydryalix range, which come in different viscosities; Gentle, Lips, Deep and Ultra Deep, and allow for personal customisation of treatment to fit patients’ needs. There is also a skinbooster, Hydryal, based on non-crosslinked HA which revitalises skin and improves elasticity, and a calcium hydroxyapatite, Crystalys, that is designed to restore facial volume and natural contours. The products are very cohesive; allowing the practitioner to really mould and sculpt the product for enhanced results and, in my opinion, good value for money.

Can you tell us about LumiFeel?

Meet the Trainer Dr Gurnam Virdi is the medical director of the Academy of Aesthetic Medicine and a key opinion leader and trainer for Luminera. He tells us about the product range and how practitioners would benefit from training

LumiFeel is a specific approach for harmonising the face. It’s all about enhancing the patient journey through a tailored approach to treatment; the LumiFeel is a play on words that emphasises that any result should help them feel better about themselves. LumiFeel involves a three-step approach that covers assessment, planning and treatment, which delegates will get fully trained on during our courses.

Tell us about your experience. How did you become an aesthetic trainer? I began practising aesthetics in 2015, after seeing lots of complications from treatments while working in A&E. I felt there may be deficiencies in training so wanted to see how I could help. After being established for two years I opened the Academy of Aesthetic Medicine in 2017 and now run training courses across the UK. I have completed Train the Trainer courses and am currently studying for a Master’s.

What makes training with you unique? I offer a very personal approach both on the courses I run and when training on behalf of Luminera, with small groups or 1-2-1 teaching. There is a strong emphasis on anatomy and we ensure all aspects of product knowledge and patient care are covered. For me it’s all about patient safety. And how do you keep a patient safe? Simple; you train the practitioner properly.

Who would benefit most from attending training sessions with you and Luminera? In my opinion, everybody would benefit, particularly newcomers in the industry. My aim is to build rapport with students to ensure they are fully confident. All delegates must be GMC, NMC or GDC registered – we do not offer training to non-medics.

Why did you decide to work with Luminera? The company sent me some products to try out about a year ago and got fantastic results, which patients were delighted with. Luminera is a research and development company based in Israel, as well as a manufacturer of injectable aesthetic devices. The company’s commitment to innovation really impressed me, as well the high regulatory standards it adheres to. 20

Aesthetics | January 2020

For me it’s all about patient safety. And how do you keep a patient safe? Simple; you train the practitioner properly


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What is a typical training day with Luminera like? All training days are focused either on using a specific product or on treating a particular area. For example, we recently ran one on using the skinbooster and our next will be geared towards non-surgical rhinoplasty. We discuss theory of the product and how it used in the morning, before the practical session in the afternoon. I assess both the technical side of things, as well as the practitioner’s communication with the patient – it’s really important that they are listening to their concerns and addressing them suitably.

Is there anything delegates should do to prior to attending the course? Literature will be sent out to delegates in advance so they have plenty of time to read up on the properties of the products and how they work. The Luminera website also hosts excellent videos showcasing live demonstrations of the products in action.

Advertorial Luminera

D EL EG AT E T ES T I MON I A L S “I’m very happy with the Luminera crossedlinked HA range, especially Hydryalix Ultra Deep. I’m injecting it in multiple areas and the results are brilliant. The Luminera skinboosters are amazing and offer three different treatments; 2%, 3% and 4%.” Dr Davina Wilson

“I’m Having CPD training at my clinic every week and I use only Luminera products; mainly Lips, Deep and Ultra Deep, as well as the Hydryal 4%, which is the best skinbooster on the market in my opinion. It’s important the newcomers in the aesthetic specialty have their first training with the best products. In addition, the price is very competitive which allows you to have a premium product at a relatively non-expensive cost.” Dr Lilyana Marks

What are the measurable outcomes for trainees and how are they assessed? Delegates will take home a lot of new information, not only about the products, but also about injecting techniques. They will discover different approaches and be able to brainstorm with other practitioners, which will ultimately make them better injectors. Delegates are also able to purchase products at the end of the training for a discounted price.

How do you ensure training is kept up-to-date? I attend international conferences almost every month and regularly speak at them too. I read clinical papers on any new products I use or teach on, ensuring everything is evidence-based. It’s so important to keep up to date with advancements and techniques in the industry.

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Aesthetics | January 2020

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Incorporating Wellness into Your Clinic With the wellness phenomenon at an all-time high, Aesthetics speaks to four practitioners about how and why they decided to introduce this element into their clinics The wellness industry has rocketed in recent years. Since 2015, it has seen a 6.4% increase with recent statistics showing that it is now worth US $4.5 trillion.1 According to the Global Wellness Institute, it comprises yoga, healthy eating, personal care, beauty, nutrition, meditation and retreats, amongst many other things.1 This, along with the increase in worldwide businesses adopting wellness services for employees2 and the spike in UK and US consumer sites and events such as Goop,3 Women’s Health5 and Bloom,4 confirms that the ‘trend’ (as some once saw it) is here to stay. But what actually is wellness? Is it an industry? A term? A movement? Well, according to the practitioners interviewed, probably all of the above. It is explained by the National Wellness Institute as ‘An active process through which people become aware of, and make choices toward, a more successful existence’.6 It’s also recognised by the Global Wellness Day website as ‘Being free from illness; a dynamic process of change and growth; a good or satisfactory condition of existence; a state characterised by health, happiness and prosperity; welfare’.7 Interestingly, aesthetic practitioner and clinic owner Dr Rosh Ravindran takes a different stance on the ‘wellness industry’. He explains, “I think it can be a misrepresented consumer-targeted monetised term. Wellness is a part of everyone; we all need connection, belonging, and our mental, physical and emotional health accounted – that’s where wellness comes in. I look at it within a psychological framework based out of relationship.” In this article, we also speak to nurse prescriber and clinic owner Julie Scott, aesthetic practitioners and clinic owners Dr Shirin Lakhani and Dr Philippe Hamida-Pisal on why, and more importantly how, they connected the world of wellness with their existing aesthetic practices.

Why have we seen a rise in wellness? “I believe the rise in the wellness industry is multifactorial,” shares Scott, explaining, “We know that social media and reality TV has a huge part to play as people now feel they can be seen at any time of the day, so they want to be looking great. However, I also think we are in a generation where people are now more commonly saying, ‘I deserve this!’ or ‘I’m going to treat myself’ and they are generally more willing to spend money on themselves, their appearance and their general health. This then snowballs. Treatments, of all kinds, are normalised and those that don’t have them think they are missing out.” Dr Lakhani recognises that people are living longer and want to be healthier in later life. “When I first started in medicine, elderly care was full of frail patients. Now, people have a lot more vitality in older age, they really want to live fulfilled and healthier lives; 70 really is the new 50!” she says. Dr Hamida-Pisal adds, “In my practice I am noticing how the pressures of the working world are affecting patients of all ages. In order to perform their very best and stay competitive, they need to make sure that they are healthy from the inside out. There are lots of life insurance companies that now also provide incentives to keep

moving and obtain healthy lifestyles, all of which I think is having an influence.”

Wellness and aesthetics All practitioners interviewed recognise that the patients who come into aesthetic clinics already have a vested interest in their appearance. However, in order for aesthetic treatments to be successful, they agree that patients have to feel good on the inside. Scott clarifies, “Emotional and physical wellness go hand in hand. If you are not emotionally and psychologically well then you cannot be physically well and what we are doing then may become redundant.” Dr Lakhani echoes this and simply says, “Aesthetic practitioners are perfectly placed to offer wellness services in their clinics.” Dr Hamida-Pisal adds, “Our patients are already concerned about the ageing process and whilst what we do is usually temporary, we need to start looking at how we can really delay the whole ageing process. This is why the first consultation is vital; I ask my patients if they smoke, how much alcohol they drink, if they follow a specific diet and whether they feel stressed at work. This then allows me to get a clearer idea of how their treatment plan will evolve.” Scott also adds that a huge benefit of incorporating wellness into your clinic is you are able to get to the root of the problem, rather than just treating it. She explains, “Once where we simply had to put a plaster over a problem, we are now able to get to the source of that problem, treat it and nurture it until you no longer need the plaster. Take a patient who is concerned with

Dr Philippe Hamida-Pisal, owner of PHP Aesthetic, says… “In my practice I incorporate a variety of services aside from general aesthetics including a nutrition and weight loss programme, full body composition checks, reiki energy healing, sports and lymphatic massages and stop smoking services. I have found that by looking at the patient’s general health and not just their common aesthetic concerns, I am able to gain lifelong patients, which of course is beneficial to my business. Being active as a speaker and trainer at many of the most important congresses and conferences in the industry, over the years I have managed to meet many highly qualified colleagues from various fields with whom I collaborate. I find it particularly useful to have the keyword ‘wellness’ associated with my online platforms as patients are now much more likely to do a Google search looking for ‘wellness doctors’ rather than general health troubles. For anyone looking to add this type of service to their clinic, I would say that they need to ensure they have a really strong network around them. This could be contracts with labs for blood tests or personal trainers to aid in sports massages, for example.”

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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their acneic skin for example, rather than just putting them on a topical regime, we would look at the gut Nurse prescriber Julie Scott, owner of Facial Aesthetics, says… health and see what’s triggering the flare ups.” “I currently offer two wellness services in my clinic and am Dr Ravindran says, “Wellness is a topic that is very looking to introduce more this year. Dr Caroline Marfleet is a current in aesthetics. People are adopting the term women’s health consultant and she joined us as the majority of ‘wellness’ into their clinics and I think everyone my patient base are peri-menopausal and menopausal women. interprets it differently. For some, it’s simply doing There was a common concern and a need for the services that the treatments, for others its adding yoga or nutrition she could provide. I was actually a personal patient of Dr Marfleet, so I knew to their practice.” He adds, “I think we need to look what an expert she was. I was very lucky to find her. at what has brought this patient into clinic and more As well as this, I’m also passionate about skin and with that comes the importantly why, in a non-threatening way. Our minds importance of gut health. As it has a large impact on one’s skin, I decided to can sometimes have a negative narrative and often introduce a food intolerance service too. I found Laura Mounteney through say something like ‘I am not successful enough’, ‘I am really good research and talking to colleagues. Finding the right people is not beautiful enough’, or ‘I am not young enough’; they tough but it can be incredibly rewarding once you do. fill in the blank of what they are not enough of with an From my patient feedback I know that they love that they can come and see internal attribution of an external or aesthetic concern. different professions all under one roof. It also means that we are getting extra Unfortunately, I think there may be some situations footfall through the door, which we may not have done previously. However, where practitioners are using patients’ vulnerabilities I don’t look at this as a revenue stream, it’s about offering my patients a more for monetary gain. Consumers do not have to justify holistic journey. This added value to my patients will consequently influence their motivations for seeking treatment, nor feel at risk my retention.” of being exploited for doing so.” He continues, “There is in fact a recent study pending publication from Stephen Dayan et al. that found that aesthetic treatments could lead Selecting your service to an increase in quality of life than antidepressants for depressive Dr Ravindran says, “Choosing your clinic’s services should come patients. It is titled ‘Are cosmetic procedures comparable to antidown to patient need and evidence-based treatments. It is vital there depressive medication for quality of life improvements? A systematic is an alignment with practitioner and patient expectation.” review and controlled meta-analysis’ and whilst I recognise the Introducing wellness services into an aesthetic clinic often involves limitations in making widespread assumptions about these findings, third-party support or the hiring of new staff. Scott says, “We are not this is what we are ultimately dealing with and trying to achieve here to diagnose when it is outside of our remit. We should always here.” refer on but, if you can, it’s preferable to do so under your own roof if you have the means.” Scott notes that it is also vital that the practitioner who you decide Dr Rosh Ravindran, owner of KLNIK, says… to work alongside respects and values your “Incorporating a wellness service into my practice was influenced morals and ethos. She shares, “I had to do a lot a lot by my personal journey. I previously worked in cardiology and of research and talk to a number of colleagues working with a multi-disciplinary team was second nature to me. for recommendations before I got the right This is something that I knew I had to introduce into my aesthetic people on board. One of the practitioners who clinic. I currently work with psychologist and body image specialist now works in my clinic was actually my personal Kimberley Cairns, known as our Personal Wellness Trainer, as well as our wellness doctor for a number of years. These people ambassador Rebecca Adlington OBE. Rebecca brings a wealth of personal are an extension of you and your brand – your experience in applying mental fitness to optimum performance. This may be most patients will expect the same service from them obvious as she is a four-time Olympic champion, but less obvious as a retired that you provide so finding the right fit is crucial.” professional athlete, a single working mother, an entrepreneur, not forgetting a Dr Lakhani says that the services you choose celebrity who has endured public body image trolling who has bravely shared can often be determined by consumer interest, her own experiences. Battling with perfectionism is a trait shared by Rebecca current zeitgeist and your individual patient and the aesthetic industry. At KLNIK we have 20 wellness modules that focus needs and desires. She explains, “Look at DNA on things such as time management, fatigue, burnout, self-esteem issues, pain sampling for example. This has seen a huge management, plus so much more. rise in popularity over the last few years and it Many of our treatments are influenced by our location. For example, Kimberley works well because it’s the most personalised also volunteers with ‘Heads Up CIO’, a world leader in the field of trauma support treatment you can get; however, you have to providing an emergency prevent and response service to those psychological make sure that your patients will be willing to affected by terror attacks. This is an important part of our network given the tragic pay for a service before you invest in it through Manchester terror attacks. We know that patients turn to aesthetics in significant thorough market research. I think this service will times or life events, for example weddings, birthdays or a new career. But I also take a while to take off here, unlike in the US, as deal a lot with patients who are grieving. It is important to keep the patient and it’s quite expensive. UK patients aren’t used to the practitioner safe when working with these potential intense emotions. To me, paying for investigation services as we have the this highlights the importance of building the right network as part of your multiNHS. Even though we have patients that come disciplinary team in your location to achieve the best emotional, mental, physical in and pay for botulinum toxin and fillers, when it and aesthetic health for our patients.” comes to paying for a blood test, they can be a bit put off.”

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Dr Shirin Lakhani, owner of Elite Aesthetics, says… “Unlike many other wellness clinics out there, I provide the additional services myself, rather than outsourcing them. This is incredibly rewarding and beneficial for me as it means that I am able to see the whole picture of the patient. This is much like the GPs we had once upon a time where they looked after the patient for their whole life; you really are invested in them. My services have a primary focus on hormones, female and intimate health and with that comes weight loss and IV drips too. However, I must stress that it is of upmost importance to be trained and confident in each area. I have gained the diploma of the Royal College of Obstetricians and Gynaecologists and have a genuine interest in how intimate health can affect someone’s life. When a patient comes into my clinic for intimate health, I am able to do a full consultation with examination (including a vaginal examination) to determine what the best treatment is for them. This isn’t something that just anyone can do. This consultation can then link through to the nutrition and hormone services that I offer, so it all ties in very nicely. Many of my patients go for general health checks even when well and bring me the results to interpret them. This is useful because it means we are not repeating tests and I am able to gather even more information on their overall health.”

The main challenges Dr Hamida-Pisal says that there can be challenges with patient compliance when it comes to wellness services. He says, “Whilst we can offer ‘wellness treatments’ such as nutrition plans and stop smoking services, we can really only advise on what they should be doing. The work often has to come from the patient as they are the ones that have to make the changes. If we are able to equip them with the knowledge and practical advice to make the everyday changes easier for them, then all they will need to do is follow a plan in order to achieve amazing results.” Scott believes that another challenge can be establishing expectations for your new practitioners. “I had a new practitioner join us and her expectations for referring new patients were very different to mine. I saw it as a reciprocal relationship whereas she thought it would be based on me feeding new patients to her. She didn’t feel that there was a need to generate her own as she was using my existing patient base. So, we sat down and established clear expectations for each of our roles and discussed how she could build new business separately. I learnt a valid lesson to be really clear about each practitioners’ expectations from the beginning. It’s absolutely a two-way thing,” she says. Dr Lakhani says, “One of the main challenges of incorporating wellness into your practice is that more and more patients are asking me to treat their general health. You need to know when to draw the line. For example, when a patient has asked me to prescribe antibiotics for a chest infection, I refused and advised them to go to their GP. However, if a patient expresses concern about weight management and hormones, as I am working in that field, I would write to the GP and see how we could work together. There is huge demand for private GPs in aesthetic clinics nowadays.” Dr Ravindran expresses the importance of continued support when you start incorporating a wellness service into your clinic, something which he believes many practitioners fail to do. He says, “What I must stress is that if you support your patient with wellness and don’t finish it, it’ll leave them more vulnerable. Equip them with suitable resources to support their needs, build their social and cognitive resilience, be a part of their team. In turn your patients know and

trust that you are available to them, that your door is always open, not just for an aesthetic treatment or monetary transaction. People can read authenticity, if you are genuinely there to help create the best version of them, they will see and feel it.”

What’s next for wellness?

All practitioners agree that the focus on wellness is just going to get bigger and will thus likely filtrate into many more aesthetic clinics. “In the future, I think we are going to see a lot of additional professions within clinics to make up an overall ‘general health’ service. This could include private GPs, minor op surgery and hair restoration services. I am certainly going to be looking to add more services to my clinic, but it’s all about cherry picking the right services to enhance your patient’s experience and undertaking your research to ensure that it will be successful,” says Scott. Dr Lakhani says she would like to see a stronger focus on gynaecology. “In the US for example, it is part of the annual routine checks by GPs and people in the UK are becoming more and more aware of these check-ups and treatments. Incorporating a gynaecological service into your clinics could be very beneficial, however it must be done by a qualified professional,” she explains. “I believe that in 2020 there will be a larger focus on nutrition and pre and probiotics in aesthetic clinics, as well as a greater understanding on how this can impact skin ageing and the metabolic system,” shares Dr Hamida-Pisal. He continues, “I think wellness in the future is all about building a solid network of reputable practitioners from different fields around us so that we can help patients from the inside out.” Dr Ravindran concludes, “I think that wellness will come to be just as important as any other modality in your clinic. Just as you train in injecting fillers for example, the same attention and dedicated training needs to be given to emotional and psychological wellness. This needs to be taken very seriously. It’s how you provide authentic services for the lifetime of a patient.” REFERENCES 1. Medium.com, The health & wellness industry is now worth $4.2 trillion, April 2018 <https://medium. com/manager-mint/the-health-wellness-industry-is-now-worth-4-2-trillion-866bf4703b3c> 2. Monster.com, 7 companies with epic wellness programs <https://www.monster.com/career-advice/ article/companies-good-wellness-programs> 3. Goop.com <https://goop.com/> 4. Bloomshow.co.uk <https://www.bloomshow.co.uk/> 5. Womenshealthmag.com <https://www.womenshealthmag.com/> 6. National Wellness Institute, The Six Dimensions of Wellness <https://www.nationalwellness.org/page/ Six_Dimensions> 7. Global Wellness Day, What is GWD? <https://www.globalwellnessday.org/about/what-is-gwd/>

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Children and Aesthetic Treatment Dr Nestor Demosthenous explores the motivations and appropriateness of aesthetic treatment in patients under 18 There is a rising concern about reports of cosmetic interventions on children1 and the appropriateness of children undergoing cosmetic interventions (surgical and non-surgical) is controversial. There are few studies looking at the psychological factors of minors who seek cosmetic treatments, or studies that look at the appropriateness of performing these procedures. Considering the increased rates of aesthetic intervention worldwide, this article will discuss the professional and legal obligations that practitioners have when children, and their parents, present to clinic seeking cosmetic interventions. In Scotland, those between 16-18 can be considered adults.2 However, in most of the UK a child is regarded as anyone under the age of 18, so for the purpose of this article, those under the age of 18 years are considered a child.

Why do children seek treatments? The desire for cosmetic interventions is prevalent in both males and females of varying socio-economic backgrounds and ages.3 The International Society of Aesthetic Plastic Surgery found a total of 31.6 million plastic surgery operations performed in 2016, with more than 63,000 surgical procedures performed in children (13-18 years) in 2013.4 According to more recent stats from The American Society of Plastic Surgeons, 227,000 cosmetic surgical and nonsurgical procedures were performed on patients aged 13 to 19 in 2018, although it should be noted that this was only 1% of the total procedures.5 As medical aesthetic practitioners, it is our professional responsibility to understand the motives of young people seeking treatments, to protect them from harm, support them in accepting themselves, and explaining the importance of prevention, helping them to live healthier lives. In today’s society, there is an emphasis on physical appearance, idealising beauty which is often unattainable.3 Media, the internet and social media play a key role in supporting the idea that our appearance is related to our success, burdening us, especially children, with psychological pressures to improve our looks.6 The greatest physical and psychological changes occur during the developmental years of adolescence. French plastic surgeon Duquennoy-Martinot identified reasons children present for cosmetic surgery, which included wanting to be ‘normal’, to feel better about themselves, be more beautiful, or emulate celebrities.7 Glamourised celebrity lifestyles portrayed in the media are recognised to drive children to seek treatments.8 A survey of 2,265 adolescents between the ages of 13 and 18 found that around 75% seek treatment to emulate celebrities, while it also suggests that girls compared to boys show greater dissatisfaction of their bodies (78%), with 31.3% wanting cosmetic surgery.9 The most common procedures were breast augmentation followed by rhinoplasties, then breast reduction and otoplasty.4

Appropriateness of aesthetic interventions Aesthetic treatments may be considered unnecessary, as cosmetic interventions, surgical and non-surgical, do not address disease or ill health. However, the World Health Organisation describes good health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’.10 This validates the idea that cosmetic procedures that are carried out can improve a patient’s psychological and social wellbeing. For example, cleft lip procedures that are not life threatening are often sought for this reason. Similarly, acne treatments are highly sought-after treatments by adolescents and it can have a profound psychological effect on children’s self-confidence.11 Acne itself is a skin ailment requiring medical treatment. The residual scarring it can leave, however, may be seen by some as purely cosmetic, yet addressing these scars can improve an adolescent’s psychological wellbeing.11 Treatment is therefore reasonable. However, where psychiatric illness is at the core of seeking interventions, treatments are not appropriate. Body dysmorphic disorder (BDD) is most common in teenagers and young adults – see BDD section.12,13 Appropriate treatment for such psychological issues involve referral to a psychiatrist/psychologist. Treatments that would alter a child’s development, for example breast or nose surgery, should be refused. Many individuals seek otoplasty procedures to correct protruding ears. As a child’s ears have fully grown to 90-95% of their full size by the age of eight years,14 surgery is not altering their development and therefore the intervention is appropriate. Surgical correction may help avoid psychological stress in early and/or later years. It should be noted that practitioners must understand who exactly is seeking the procedure – child or parent/ guardian. The parent may be seeking treatments for their child for their own reasons/prejudice (for example protruding ears), however this anomaly may not bother the child at all. Ultimately, it is the responsibility of the practitioner to decline treatments deemed inappropriate, such as a sixteen-year-old patient seeking botulinum toxin for ageing concerns when facial lines are not present. Girls do not attain adult lip dimensions until the age of 17/18 and boys 18/19 years of age. Treating them with lip fillers before this should therefore be considered inappropriate.15 All surgical and non-surgical interventions carry the risk of complications/harm. One of the four pillars of Good Medical Practice is ‘do no harm’ so to perform a treatment such as botulinum toxin for cosmetic reasons on a child as an elective procedure, where the risks outweigh the benefits, would be wrong.16 This moral compass should be present in every decision a practitioner makes. A child may lack the maturity to appreciate that the requested treatment may cause harm. For example, Ellart et al. found that 14% of sixteen-year-old girls wanted a breast augmentation procedure, often to a size that could cause complications such as postural or respiratory problems.17

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Body dysmorphic disorder Most often, BDD develops in teens and adolescents.12,13 A recent survey published in 2018 by NHS Digital consisting of 9,117 children aged 2-19 suggested that BDD is prevalent in 1% of 5 to 19-year-olds. The research also found that it affects 1.8% of girls and 0.3% of boys. Rates were highest in girls aged 17-19, with 5.6% experiencing BDD at the time of the interview.13,28 Statistics are slightly different in the US. According to the Anxiety and Depression Association of America, it is thought that 1.7-2.4% of the population suffer from BDD12 and it affects men and women almost equally – 2.5% of males and in 2.2 % of females.12 BDD is characterised by a preoccupation with an imagined defect in one’s appearance, or in the case of a slight physical anomaly, the person’s concern is markedly excessive. BDD is characterised by time consuming behaviours such as mirror gazing, comparing particular features to those of others, excessive camouflaging tactics to hide the defect,

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skin picking and reassurance seeking.12,13 National Institute for Health and Care Excellence (NICE) guidelines state that for people known to be at a higher risk of BDD (such as individuals with symptoms of depression, social phobia, alcohol or substance misuse, OCD or an eating disorder), or for people with mild disfigurements or blemishes who are seeking a cosmetic procedure, healthcare professionals should routinely consider and explore the possibility of BDD.29 If BDD is suspected, NICE suggests that the patient should be referred to their GP to then be referred onto a specialist BDD multidisciplinary team offering age-appropriate care. Depending on the severity of the BDD, the patient may be treated with cognitive behavioural therapy, involving family or carers, with the possible addition of selective serotonin reuptake inhibitors (SSRI) antidepressants.29 According to NICE, the assessment of people at higher risk of BDD should be asked the following questions:29

It is also important for the practitioner to know which conditions children will outgrow. Greydanus et al. found that although breast asymmetry in young girls and the presence of breast tissue in young boys cause depression and low self-esteem in children, it often resolves in adulthood.18 With regards to potential non-surgical rhinoplasty treatments, the female nose develops around the age of 17, the male nose approximately 18. Treatment before these ages would be inappropriate.19 Therefore, practitioners should advise patients accordingly, and not comply with treatment request, but help support their mental wellbeing during this time by referring them to an appropriate psychologist or their GP. As well as this, concerns and desires (and trends) are likely to change through adolescence. One study by Wright found that adolescents’ ideas of body image improved between the ages of 11 and 18 without interventions.20 It is the practitioner’s obligation to initiate these kinds of discussions to help the patient realise insight. A practitioner must seek to understand the patient’s (or parents’) motivation for treatments, assess how long they have wanted treatment and what they hope treatment will achieve. They should even go as far as to point out how concerns, wants and trends change over the years and that the patient should consider waiting a couple of years. Guidance on treating children These professional and legal responsibilities for treating children are outlined in the General Medical Council’s (GMC) ‘Guidance for doctor’s who offer cosmetic interventions’.21 For patients of all ages, the guidance advises withholding treatment if the desired outcome will not be achieved or if there would be no benefit; and to consider a patient’s vulnerabilities and psychological needs.21 It also advises a cooling-off period allowing time for

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1. Do you worry a lot about the way you look and wish you could think about it less? 2. What specific concerns do you have about your appearance? 3. On a typical day, how many hours a day is your appearance on your mind? 4. What effect does it have on your life? 5. Does it make it hard to do your work or be with friends? Practitioners can use the Derriford Appearance Scale30 – a validated and arguably one of the more reliable psychometric scales – to measure the expectations of how one’s looks could be improved and to what extent their quality of life would be improved following surgery. This can help to identify BDD. It measures the extent that psycho-social distress is linked to physical appearance. A reasonable argument for treatment would be if a child’s psychological distress caused by BDD results in difficulties to function within society, resulting from social isolation and withdrawal.31

reflection.21 They do not clarify what constitutes a ‘cooling-off period’ for non-surgical procedures, however two weeks is considered appropriate for surgical procedures. Specifically relating to children, the GMC recommends to carry out treatments in a child-friendly environment and to only perform procedures that are in the child’s best interest.21 Parents know the patient best, are an important mediator between practitioner and patient, and can provide useful insight into why a child is requesting a procedure, as well as help explain the risks involved and why a procedure may be refused. Therefore, the GMC states that a parent can consent to an intervention for a child ‘that lacks the maturity’ to make the decision; however, doctors can decline treatment if they believe the child does not want it.21 Children should be appropriately involved in decision making, respecting their autonomy. The GMC also says that practitioners must seek to help the child/parent become aware of their own subjectivity of severity and realise the risk perhaps outweighs the benefit of what they are asking.21 They should also recommend alternative, lessinvasive measures, such as diet and exercise vs. liposuction. There is no specific guidance for nurses who offer cosmetic interventions by the Nursing and Midwifery Council; however, the British Association of Cosmetic Nurses state in its 2015 Competency Framework that, ‘It is generally accepted that the patient should be over 18 years of age to access aesthetic medical services in order to provide full consent for elective, non-emergency procedures.’22 The same goes for dentists, however they must adhere to the General Dental Council’s general ‘Guidance on child protection and vulnerable adults’, which is nonspecific to cosmetic interventions like dermal fillers.23

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Consent and capacity As with all treatments, practitioners must obtain informed consent prior to intervention. As part of informed consent, treatment options must be offered, intended outcomes of proposed treatment with associated risk must be discussed as well as the likelihood of these risks. Fundamentals of informed consent include receiving appropriate information, capacity and voluntariness. The GMC’s guidance for doctors on treating 0-18 years is clear on assessing the capacity of the patient.23 Before obtaining consent, a doctor must decide if a child is able to understand the nature, purpose and possible consequences of treatments, or not having treatment.24 With regards to capacity, of importance is a child’s ability to understand and weigh options, rather than age. Maturity and understanding must be assessed on an individual basis. If a child under the age of 16 is deemed to have ‘enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment’, they are deemed to be Gillick competent.25,26 In children who lack capacity, a parent’s consent is acceptable. It is paramount that the parent’s motivations are explored when cosmetic interventions are sought. Parents may seek such treatments out of an effort to realise ‘the ideal child’ or in the case of congenital deformities, out of guilt.7 A practitioner must understand the motivations of the parent/guardian in the case of an incompetent child. For example, in a child with Down’s syndrome, parents may seek corrective surgery to alter facial features. Surgery purely at the request of the parents is not acceptable. Surgery will not affect the child’s interaction with society and quality of life.1 The legal framework for the treatment of 16 and 17-year-olds lacking capacity to consent differs across the UK. In England, Wales and Northern Ireland parents can consent to treatments in a child’s best interest.27 In England and Wales, treatment may be provided in a child’s best interest without parental consent.27 In Scotland, patients aged 16 and 17 are treated as adults who lack capacity.27 Treatment may be given to safeguard or promote their health.

Conclusion Cosmetic procedures can have positive psycho-social benefits such as improved self-esteem and quality of life.32 Cosmetic treatments may be offered to children, however with caution. When a child, or parent of the child, seeks non-surgical or surgical cosmetic interventions, the practitioner must act in the patient’s best interest, do no harm and observe the law. Manufacturers of products and devices used in a cosmetic medicine often carry guidelines for age-appropriate use. This is usually in the form of ‘Contra-indications: children’, however they do not qualify how they define a child. The consultation should be well structured to enable practitioners to understand the child’s/ parent’s motivation and these reasons should be explored before making a decision to treat or not. Capacity must be determined and consent gained. Any suspicion of BDD must be referred appropriately. Young patients are more often vulnerable and must be supported and respected. Ample information must be given and a cooling-off period applied if proceeding to treatment. Practitioners retain the right to refuse treatment if deemed inappropriate.

Dr Nestor Demosthenous is one of Scotland’s most experienced cosmetic doctors. He is an international speaker and published author in the specialty. Dr Nestor has been an advisory board member for Allergan’s complications group 2015, and Healthcare Improvement Scotland Phase I (2016-7) & II (2017-8). He has previously been a key opinion leader for Sinclair Pharma and is currently a member of Allergan’s Medical Institute Mentorship Program. REFERENCES 1. Bowyer L1, et al., A critical review of cosmetic treatment outcomes in body dysmorphic disorder Body Image. 2016 Dec;19:1-8 2. Citizens Advice for Scotland, Young people and the law. <https://www.citizensadvice.org.uk/scotland/ law-and-courts/legal-system-s/taking-legal-action-s/young-people-and-the-law-s/> 3. Vergallo GM, Marinelli E, Napoletano S, Di Luca NM, Zaami S. Ethics and/ or Aesthetics? Reflections on Cosmetic Surgery for Adolescents. Cuad Bioet. 2018 May-Aug; 29(96):177-189. 4. International Society of aesthetic plastic surgery. 2019. ISAPS. <https:// www.isaps.org/medicalprofessionals/isaps-global-statistics/> 5. American Society of Aesthetic Plastic Surgeons, ASPS National Clearinghouse of Plastic Surgery Procedural Statistics, 2018. <https://www.plasticsurgery.org/documents/News/Statistics/2018/plasticsurgery-statistics-full-report-2018.pdf> 6. Rufai, S.R.; Davis, C.R. “Aesthetic surgery and Google: ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery”. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014; 67(5): 640-643. 7. Duquennoy-Martinot V, et al., Is cosmetic surgery proposal to children and adolescents wellfounded?]Ann Chir Plast Esthet. 2016 Oct;61(5):622-628. Epub 2016 Jun 8. 8. Gunn, E.G.; Loh, C.Y.; Athanassopoulos, T. “Cosmetic web- sites Scotland: legal or lurid”. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014;67(8):1144-7. 9. Portale Della Medicina Estetica. 2019. Portale Della Medicina Estetica. <https://www. lamedicinaestetica.it/index.php/pubblicazioni-scientifiche/> 10. World Health Organisation. 2019. About WHO. <https://www.who.int/about/who-we-are/constitution> 11. Al-Talib, H.; Al-Khateeb, et al., “Efficacy and safety of superficial chemical peeling in treat- ment of active acne vulgaris”. Anais Brasileiros de Dermatologia. 2017;92(2):212-216. 12. ADAA, Body Dysmorphic Disorder (BDD) <https://adaa.org/understanding-anxiety/related-illnesses/ other-related-conditions/body-dysmorphic-disorder-bdd> 13. Franziska Marcheselli, England’s first estimates of body dysmorphic disorder prevalence in children and young people, NatCen, 2018. < http://natcen.ac.uk/blog/englands-first-estimates-of-bodydysmorphic-disorder-prevalence-in-children-and-young-people> 14. Farkas LG1, Posnick JC, Hreczko TM. Anthropometric growth study of the ear. Cleft Palate Craniofac J. 1992 Jul;29(4):324-9. 15. Ferrario VF1, et al., Normal growth and development of the lips: a 3-dimensional study from 6 years to adulthood using a geometric model.J Anat. 2000 Apr;196 ( Pt 3):415-23. 16. Medical protection society. 2000. Essential learning: Law and ethics. <https://www.medicalprotection. org/uk/articles/essential-learning-law-and-ethics> 17. Ellart, J, et al., “Breast asymmetry of the teenager and the young adult. Stability of the result in time. About 144 patients”. 2016:61 (5) 665-679. 18. Greydanus, D.E.; Matytsina, L.; Gains, M. “Breast disorders in children and adolescents”. Primary Care. 2006;33(2):455-502. 19. Carel D. A. Verwoerd & Henriette L. Verwoerd-Verhoef, Rhinosurgery in children: developmental and surgical aspects of the growing nose GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010; 9 20. M.R. Wright. Body image satisfaction in adolescent girls and boys: a longitudinal study. J Youth Adolesc, 18 (1988), pp. 7183 M.R. Wright. Body image satisfaction in adolescent girls and boys: a longitudinal study. J Youth Adolesc, 18 (1988), pp. 7183 21. GMC. 2019. 0-18 years: Guidance for all doctors. <https://www.gmcuk.org/ethical-guidance/ethicalguidance-for-doctors/0-18-years> 22. BACN, 2015 Competency Framework, 2015. <http://www.bacn.org.uk/ content/56e95e6b8a8781.43460561.pdf> 23. GDC, Guidance on child protection and vulnerable adults < https://www.gdc-uk.org/docs/ default-source/guidance-documents/guidance-on-child-protection-and-vulnerable-adults. pdf?sfvrsn=eebbd01b_2> 24. GMC. 2019. Cosmetic Interventions Content. <https://www.gmc-uk.org/ethical-guidance/ethicalguidance-for-doctors/cosmetic-interventions/key-points> 25. NHS. 2019. Children and Young people, consent to treatment. <https://www.nhs.uk/conditions/ consent-to-treatment/children/> 26. C Harrison, N P Kenny, M Sidarous, and M Rowell Bioethics for clinicians: 9. Involving children in medical decisions CMAJ. 1997 Mar 15; 156(6): 825–828. 27. Mddu. 2000. Consent and young patients. <https://www.theddu.com/guidance-and-advice/guides/ consent-and-young-patients> 28. NHS Digital, Mental Health of Children and Young People in England, 2017, November 2018. <https:// digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-youngpeople-in-england/2017/2017> 29. National Institute for Health and Care Excellence, June 2019 ‘Obsessive-compulsive disorder and body dysmorphic disorder overview’. <https://pathways.nice.org.uk/pathways/obsessive-compulsivedisorder-and-body-dysmorphic-disorder/obsessive-compulsive-disorder-and-body-dysmorphicdisorder-overview.pdf> 30. Derriford. 2010. Derriford Appearance Scale, 7 January 2019, <http://www.derriford.info> 31. Singh. K. “Cosmetic Surgery in Teenagers: To Do or Not to Do”. . 2015; 8(1): 57–59 32. RJ Honigman , KA Phillips , Castle DJ A review of psychosocial outcomes for patients seeking cosmetic surgery Plast Reconstr Surg , 113 ( 2004 ), pp. 1229 1237.

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Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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InBody Score

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33.9

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2.63

36.1

(36.7 ~ 44.8)

(2.49 ~ 3.05)

59.1

(45.0 ~ 60.8)

23.0

55

70

(kg)

70

80

(kg)

40

60

66 / 100

85

100

90

80

18.8

115

130

100

110

120

100

160

220

59.1

145

160

175

190

205

130

140

150

160

170

280

340

400

460

520

23.0

Points

Total score that reflects the evaluation of body composition. A muscular person may score over 100 points.

Weight Control

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(kg)

ZZZLQERG\FRP

Female 201.05.04. 09 : 46

53.0 kg - 6.1 kg - 10.8 kg + 4.7 kg

Target Weight Weight Control Fat Control Muscle Control

Obesity Evaluation BMI

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PBF

Normal

Slighty Over

Slighty Over Over Over

Body Balance Evaluation (kg/m2)

(%)

(kg) (%) (kg) (%) (kg) (%) (kg) (%)

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(kg) (%)

10.0

15.0

18.5

21.0

25.0

30.0

35.0

8.0

13.0

18.0

23.0

28.0

33.0

38.0

40

60

80

40

60

80

70

80

90

80

70

70

45.0

50.0

55.0

48.0

53.0

58.0

140

160

180

200

220

240

100

120

140

160

180

200

220

240

100

110

120

130

140

150

160

170

90

100

110

120

130

140

150

160

170

80

90

100

110

120

130

140

150

160

170

0.340

0.360

0.380

0.390

0.400

0.410

0.420

0.430

0.440

0.450

4.78 75.5

1.82 90.8 17.0 93.5

0.397

Balanced

Extremely Unbalanced Extremely Unbalanced Extremely Unbalanced

Segmental Fat Analysis

120

1.89 94.4

Balanced

Upper-Lower

Slightly Unbalanced Slightly Unbalanced Slightly Unbalanced

( 1.7kg) ( 1.8kg) (12.4kg) ( 3.0kg) ( 3.0kg)

Right Arm Left Arm Trunk Right Leg Left Leg

194.4% 198.4% 248.5% 132.1% 131.3%

Research Parameters Intracellular Water 15.9 Extracellular Water 10.7 Basal Metabolic Rate 1149 Waist-Hip Ratio 1.00 Visceral Fat Level 14 Obesity Degree 112 Bone Mineral Content 2.15 Body Cell Mass 22.8 Arm Circumference 29.6 Arm Muscle Circumference 25.0

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65.3

63.9

20.1

20.0

41.3

40.7

0.399 0.398 Recent

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40.0

43.0

38.9

100

4.86 76.7

0.320

24.0

Balanced

Upper Lower

62.4

61.8

62.3

60.9

60.5

19.7

19.7

19.8

19.7

19.8

39.2

39.0

39.4

38.6

37.8

59.1 18.8 38.9

0.398 0.397 0.396 0.396 0.397 0.396

14.10.30 14.11.02 14.12.15 15.01.12 15.02.10 15.03.15 15.05.04 Total 14.10.10 09:15 09:40 09:35 11:01 08:33 15:50 08:35 09:46

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Impedance

RA

Č?

LA

TR

RL

LL

373.1 385.4 25.7 303.0 314.1 337.2 352.5 23.0 282.3 289.8 297.4 311.5 19.1 258.1 267.8


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Eating low GI foods and avoiding processed sugars may therefore reduce acne flares in patients with and without concurrent PCOS,10,19,20 and one study showed that women with elevated IGF-1 levels are more likely to experience acne compared to men.19 I use an inDermatology nurse practitioner Emma Coleman depth consultation with acne patients to identify possible dietary issues alongside first-line topical explains how one’s diet can influence skin and preparations. Studies have shown that soybean isoflavones hair and presents a supporting case study (a type of phytoestrogen) exert an antiThe effects of diet on skin is a controversial subject due to a androgenic effect, altering disease pathways and skin health.13,21 lack of strong evidence justifying this as an effective element Furthermore, there is data supporting a positive correlation in dermatology treatment. However, there is growing support for between eating foods rich in soybean isoflavone and acne multi-disciplinary approaches to the management of skin disease lesion reduction, due to inhibition of the steroidogenic due to evidence of higher success and faster discharge rates.1,2 This hormone-inducing enzymes 3ß-hydroxysteroid dehydrogenase, approach is something I incorporate into my daily practice. 17ß-hydroxysteroid dehydrogenase and 5α-reductase.13,21 In this article, I discuss the benefits of combining dietary and oral/ One study found that combining soybean supplementation topical preparations in management of four endocrine-induced skin (160mg daily) with 0.025% tretinoin cream and SPF 15 sunscreen conditions: acne vulgaris, hirsutism, menopausal skin ageing and over 12 weeks significantly reduced acne lesion number in female female pattern hair loss (FPHL). patients.21 Such dermatology conditions may cause psychological disruption to Isoflavones contain antioxidant and antifungal properties. sufferers, resulting in feelings of shame, humiliation and depression.3,4 Soybeans have four chemical types; aglycone, glucosides, One study reported that 5.6% of acne vulgaris patients have suicidal acetyl glucosides and aminoglycosides, containing the three ideation.3 There is also evidence that diet may influence hormonal isoflavones daidzein, genistein and glycitein. Soybean isoflavone homeostasis in those who are experiencing these skin conditions, foods can be eaten in the fermented form; miso, tempeh, natto, imparting skin and hair changes. Diet as a management tool may be soy sauce for instance or non-fermented; soy milk, tofu, soybean used in conjunction with appropriate oral or topical preparations to sprouts. There is insufficient evidence to support that soy help accelerate symptom control. 5-16 products negatively affect hormone function in men and women22 and some studies have shown that soy exerts positive effects Acne vulgaris on oxidative stress, cholesterol and bone density in men and There is evidence to suggest that acne vulgaris is very common post-menopausal women.23,24 Some of these foods can exert an in western populations, with statistics showing that 79-95% of additional probiotic effect.25 adolescents of both sexes are affected, and 40-54% of women and men aged over 25 years.5 Acne is caused when sebaceous Hirsutism glands become widened due to androgen targeting, stimulating Mild to moderate androgen abnormality and PCOS is associated prolific sebum production.17 This often commences during with approximately 65% of hirsutism cases, where prolific hair adolescence when the production of the sex hormone precursor growth can commonly be seen on the upper lip, chin, chest and dehydroepiandrosterone sulphate by the adrenal glands is areola in female patients.5 It is thought to occur largely due to hair heightened. There is some data supporting presence of higher follicle hyper-sensitivity to androgens, enlarging dermal papillae androgen-receptor sensitivity and density in acne-prone skin.5-7 and altering duration of hair growth during adolescence, often Acne is less common amongst Asian populations, thought to be due increasing with age.26 It is reported that 20% of cases are idiopathic, not only to genetic factors, but also the dairy-driven western diet characterised by prevalence of dihydrotestosterone (DHT) induced in comparison to low dairy consumption seen in Asian countries.7 thickened hair growing on androgen-sensitive skin parts.25 Similar Evidence suggests that daily consumption of two glasses of full fat or to acne in its signalling and pathways, hirsutism often occurs as skimmed milk leads to significantly greater glycaemic index (GI) and a result of insulin-induced IGF1 release, and subsequently lowers glycaemic load (P = .022 and P = .001, respectively), in patients with sex hormone-binding globulin, increasing levels of circulating acne compared to controls, whilst a low body mass index (BMI) and testosterone.14 8 eating fish three times weekly appears to exert a protective effect. A weight loss programme combined with oral metformin to One Turkish paper describes a positive correlation between high stabilise insulin, the combined contraceptive pill and, in some GI diet and acne development in 50 subjects.9 Consuming milk and cases, spironolactone can improve PCOS and reduce symptoms of hyperglycaemic foods may induce insulin production, leading to hirsutism by reducing androgen levels.27,28 sebocyte and keratinocyte proliferation plus sebaceous lipogenesis, As an adjuvant therapy, there are some dietary elements which significantly increasing acne lesions.10 I include for my hirsutism patients. One small scale study found A significant proportion of females aged 17 to 40 years with resistant that women who drank spearmint tea twice daily for five days had acne vulgaris have polycystic ovary syndrome (PCOS).11,12 Insulin decreased free testosterone levels and increased serum levels of production heightens androgen production by stromal cells of the luteinising and follicle-stimulating hormones as well as estradiol.29 As ovaries; hyperinsulinemia increases hepatic insulin growth factor 1 there is some evidence to suggest that dietary soy-phytoestrogens (IGF-1) production, stimulating sebum gland activity and increasing reduce plasma testosterone levels by approximately 50%,15 I would 10,18 keratinocyte proliferation, leading directly to comedo formation. also recommend inclusion of these food groups and reduced sugar

Diet and Endocrine-induced Skin Conditions

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Adverse Adverse events events should should be reported. be reported. Reporting Reporting forms forms andand information information cancan be found be found at at https://yellowcard.mhra.gov.uk. https://yellowcard.mhra.gov.uk. Adverse Adverse events events should should alsoalso be reported be reported to Allergan to Allergan Ltd.Ltd. UK_Medinfo@allergan.com UK_Medinfo@allergan.com or 01628 or 01628 494026. 494026. References: References: 1. Allergan. 1. Allergan. Unpublished Unpublished data. data. INT/0484/2018. INT/0484/2018. Number Number of cycles, of cycles, systems systems andand accounts accounts to date. to date. October October 2018. 2018. 2. Allergan. 2. Allergan. Unpublished Unpublished Data. Data. INT/0771/2016(2). INT/0771/2016(2). ® ® , the , the world’s world’s leading leading brand brand of hyaluronic of hyaluronic acidacid facial facial fillers. fillers. FebFeb 2019. 2019. JUVÉDERM JUVÉDERM

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of genistein on menopausal features can be achieved at a specific dosage of 54 mg/day.13 A post-menopausal female aged 56 years To my knowledge, there are no reputable presented in clinic with dry, dehydrated skin, facial oestrogen skincare products on the evidence of deep cheek rhytids and reported market, however the protective, moisturising accelerated ageing over an average of three and anti-inflammatory benefits of flavonoids, years. The patient had no accompanying skin curcuminoids, niacinamides and peptides conditions. She had not had a period for at least found in polyphenols are being increasingly one year but was experiencing hot flashes, sleep explored36 and ceramides help to restore disturbance, mood swings and anxiety at initial skin barrier function,38 making these elements consultation. She was a social smoker and drinker, my go-to recommendations to help restore consuming around three to five units weekly. She elasticity and hydration. Based on research, Figure 1: A 56-year-old patient before drinks caffeine daily. The patient had a main focus and 12 months after treatment I also supply dietary information, focusing on on restoring epidermal thickness and hydration aglycone genisteins (fermented forms), plus over one year. I put her on isoflavone and synbiotic supplements, provided realistic supplementation of 54mg daily, for patients at and bespoke dietary programmes including phytoestrogen-rich sources, reduced all stages of their menopausal phase.13,37 caffeine, white wine and prosecco intake, (association with skin inflammation and Minoxidil 5% foam is generally the treatment grape-based alcohol is documented)47,48 alongside provision of a regimented antioxidant of choice in menopausal female pattern hair and sunscreen-heavy skincare regime. Additionally, I treated her with microneedling loss,39 although in my experience there is (mesotherapy alternated with SkinPen) and LED light therapy every six weeks over often poor treatment adherence. Studies 12 months, using these appointments as an opportunity to assess adherence and have reported variable success rates in tolerance. At the start of therapy, the average left eye wrinkle length was 7.8cm, treatment of FPHL with hormone replacement spanning a 5.2cm area, reducing to 1.8cm and 1.9cm respectively at the 12-month point. therapy; oral finasteride yields better The skin appeared plumper and firmer following treatment. results.40-42 Decreasing androgen secretion and thereby circulating testosterone has a positive effect on hair regrowth,39 suggesting intake in my patient group. Yams, lentils, alfalfa and mung beans, flax, that isoflavone ingestion through diet or supplementation may reduce sunflower and sesame seeds are also good phytoestrogen sources.30 hair loss. There is insufficient evidence to support relying solely on diet and supplementation.

Case study

Menopausal skin and hair loss Skin changes leading to ageing are accelerated during the peri and menopausal years due to a decline in oestrogen and progesterone receptors residing in dermal fibroblasts and epidermal keratinocytes.31,32 This can lead to skin thinning, loss of elasticity and increased wrinkle formation.32 Additionally, this reduction in oestrogen receptors can cause lengthening of the anagen phase of hair growth, which can lead to frontal fibrosing alopecia in the post-menopause period.33 The cutaneous changes we see in skin at peri and postmenopausal stages are largely due to extensive decline in alpha (ERa) and beta (ERb) oestrogen receptors, leading to reduction in stromal collagen synthesis. Hormonal supplementation may reverse these changes; however, hormone replacement therapy poses certain risks and is not for everyone, so alternative options are important in symptom management.34 ERas are limited to the dermis, whereas ERbs are spread throughout the dermis, around hair follicle bulbs and the epidermis.13 One study showed that the isoflavone genistein acts as a selective oestrogen receptor modulator (SERM), binding to and reactivating ERb proliferation, suggesting it may have a beneficial effect in decelerating ageing by restoring epidermal thickness through collagen synthesis.35 Another human study provided evidence that even in low doses, oral genistein is able to disrupt IGF1 pathways, exerting a protective effect on dermal fibroblasts to prevent oxidative stress-induced collagen biosynthesis inhibition.16 Another trial compared effects of application of topical oestrogen with isoflavone in post-menopausal women, and showed that oestrogen leads to higher epidermal thickening and increases in fibroblast and dermal papillae number compared to topical isoflavone therapy.36 Dietary fermented aglyconerich soy foods are absorbed faster and in greater amounts compared to glucoside rich soy in postmenopausal Japanese women.37 The beneficial effects

A note about pro and prebiotics Dermatologists Dr John Stokes and Dr Donald Pillsbury hypothesised 70 years ago that the emotional state of a person (such as depression, worry and anxiety) will affect gut micro flora by causing small intestine bacteria overgrowth (SIBO) contributing to skin imbalance.43-45 Findings from one study suggest that lactobacillus paracasei therapy inhibits substance P-induced inflammation.44 Including fermented milk drinks such as kefir in your diet or quality symbiotic supplement therapy could therefore help to break the mind-gut-skin cycle in endocrinal skin conditions. For those patients experiencing teenage or adult acne, I would recommend kefir derived from coconut or soy milk for reasons discussed previously.5,46

Conclusion Adopting a low GI diet with reduced dairy intake for acne vulgaris sufferers, and a diet rich in phytoestrogens in all patient groups discussed here could speed up symptom resolution, but should be used in conjunction with traditional approaches rather than in isolation. In menopausal skin, diet and skincare combined may improve elasticity and reduce surface wrinkles. Probiotics may have a role in balancing gut micro-flora and reducing skin inflammation. Emma Coleman is an aesthetic and dermatology nurse practitioner with award-winning clinics across London and Kent. She frequently speaks and writes about taking a holistic approach to skin ageing and dermatology. She has also launched her own natural, antioxidant skincare line.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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REFERENCES 1. Anthony Bewley and others, ‘Working Party on Minimum Standards for Psychodermatology Services.’ British Association of Dermatologists. (2012) http://www.bad.org.uk/shared/getfile. ashx?itemtype=document&id=1622 (pp 1-10) 2. Raj Shah and others, ‘A Pilot Study Looking at the Outcome Evaluation of Psychological Services in Dermatology: Effectiveness and Cost Analysis.’ Int Journ Womens Dermatol. (2015) 4(1): https://www. sciencedirect.com/science/article/pii/S2352647517300837 (pp8-11) 3. Habib Ansarin and others, ‘Clinical Presentation and Etiologic Factors of Hirsutism in Premenopausal Iranian Women,’ Arch Iranian Med 10 (1) (2007): http://ams.ac.ir/AIM/NEWPUB/07/10/1/004.pdf (pp 7–13) 4. Shah R, 2012. Psychological Effects Scar the Mind. (London, www.Raconteur.net 2012) 5. Loren Cordain and others, ‘Acne Vulgaris: A Disease of Western Civilisation Archives of Dermatology.’ Arch Dermatol. (2002) https://www.ncbi.nlm.nih.gov/pubmed/12472346 138(12) (pp1584-1590) 6. Mary Stewart and others, ‘Sebaceous Gland Activity and Serum Dehydroepiandrosterone Sulfate Levels in Boys and Girls.’ Arch Dermatol :128 (10) (1992): https://jamanetwork.com/journals/ jamadermatology/article-abstract/554420 (pp1345–1348) Cited by: Zouboulis and others, ‘What is the Pathogenesis of Acne?’ Experimental Dermatology 14. (2005) https://onlinelibrary.wiley.com/doi/ epdf/10.1111/j.0906-6705.2005.0285a.x: (pp 143-152). 7. Loren Cordain and others, ‘Acne Vulgaris: A Disease of Western Civilisation Archives of Dermatology. Arch Dermatol. 138(12) (2002) https://www.ncbi.nlm.nih.gov/pubmed/12472346 (pp 1584-1590) 8. Landro A, Cazzaniga S, Parazzini S, Ingordo V, Cusano S, Atzori L, Cutfri F, Musumeci M, Zinetti C, Pezzarossa E, Betolli V, Caproni M, Lo Scocco G, Bonci A, Bencinni P, Naldi L. 2012. Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults.J Am Acad Dermatol. 2012 Dec;67(6):1129-35 Available from: https:// www.ncbi.nlm.nih.gov/pubmed/22386050 9. Çerman A, Aktas E, Altunay I, Arici J, Tulunay A, Ozturk F.2016. Dietary glycemic factors, insulin resistance, and adiponectin levels in acne vulgaris. J Am Acad Dermatol. 2016 Jul;75(1):155-62 Available from: https://www.ncbi.nlm.nih.gov/pubmed/27061046 10. Rashmi Kumari and others, ‘Role of Insulin Resistance and Diet in Acne’ IJDVL: 79(3) (2013) http://www. ijdvl.com/article.asp?issn=0378-6323;year=2013;volume=79;issue=3;spage=291;epage=299;aulast=K umari (pp291-299) 11. Julia Newton and others, ‘Most Women With Acne Have Polycystic Ovaries’ BJD: 121(6) (1989) https:// onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2133.1989.tb08208.x (pp 675-680) 12. Johana Lampe and others, ‘Soy Protein Isolates of Varying Isoflavone Content Exert Minor Effects on Serum Reproductive Hormones in Healthy Young Men1’ Journal of Nutrition: 135(3) (2005)https:// www.researchgate.net/publication/7998957_Soy_Protein_Isolates_of_Varying_Isoflavone_Content_ Exert_Minor_Effects_on_Serum_Reproductive_Hormones_in_Healthy_Young_Men1 (pp584-591) 13. Natasha and others, ‘Dietary Management of Skin Health: The Role of Genistein’ Nutrients: 9(6) (2017) https://www.mdpi.com/2072-6643/9/6/622/htm (pp622) 14. Renato Pasquali and others, ‘Insulin-Sensitizing Agents in Polycystic Ovary Syndrome’ Eur J Endocrinol: 154(6) https://eje.bioscientifica.com/view/journals/eje/154/6/1540763.xml (pp 763-75) 15. Karen Weber and others, ‘Dietary Soy-Phytoestrogens Decrease Testosterone Levels and Prostate Weight Without Altering LH, Prostate 5-Reductase or Testicular Seroidogenic Acute Regulatory Peptide Levels in Adult Male Sprague–Dawley Rats’ Journal of Endocrinology:170 (2001) http:// weberlab.byu.edu/Portals/105/Publications/Journal%20of%20Endocrinolgy%20(2001).pdf (pp 591–599) 16. Pawel Sienkiewicz and others, ‘Nutritional Concentration of Genistein Protects Human Dermal Fibroblasts From Oxidative Stress-Induced Collagen Biosynthesis Inhibition Through IGF-I ReceptorMediated Sgnaling.’ Acta Pol. Pharm. 65(2) (2008) https://europepmc.org/abstract/med/18666426 (pp 203–211 17. Zouboulis and others, ‘What is the Pathogenesis of Acne?’ Experimental Dermatology 14. (2005) https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.0906-6705.2005.0285a.x: (pp 143-152). 18. Hiroshi Aizawa and others, ‘Elevated Serum Insulin‐like Growth Factor‐1 (IGF‐1) Levels in Women with Postadolescent Acne’ The Journal of Dermatol: 22(4) (1995) https://onlinelibrary.wiley.com/doi/ abs/10.1111/j.1346-8138.1995.tb03381.x (pp249-252) 19. Mark Cappel and others, ‘Correlation Between Serum Levels of Insulin-like Growth Factor 1, Dehydroepiandrosterone Sulfate, and Dihydrotestosterone and Acne Lesion Counts in Adult Women’ Arch Dermatol:141(2) (2005) https://jamanetwork.com/journals/jamadermatology/articleabstract/393279 (pp333-338) 20. Teresa Norat and others, ‘Diet, Serum Insulin-Like Growth Factor-I and IGF-Binding Protein-3 in European Women’ Eur J Clin Nutr: 61(1) (2007) https://www.ncbi.nlm.nih.gov/pubmed/16900085 (pp 91-98) 21. Puguh Riyanto and others, ‘Advantage of Soybean Isoflavone as Antiandrogen on Acne Vulgaris’ Dermato-Endocrinology: 7(1) (2015) https://www.tandfonline.com/doi/full/10.1080/19381980.2015.1063 751 22. Mark Messina and others, ‘Effects of Soy Protein and Soybean Isoflavones on Thyroid Function in Healthy Adults and Hypothyroid Patients: A Review of the Relevant Literature’ Thyroid: 16(3) (2006) https://www.liebertpub.com/doi/pdf/10.1089/thy.2006.16.249 23. Susan Potter and others, ‘Soy protein and isoflavones: their effects on blood lipids and bone density in postmenopausal women’ Am Journ Clin Nutr: 68(6) (1998) (pp 1375S-2379S) 24. Zora Djuric and others, ‘Effect of soy isoflavone supplementation on markers of oxidative stress in men and women’ Cancer Letters: 172(1) (2001) 25. Huei-Ju and others ‘Isoflavone Content in Commercial Soybean Foods’ J Agric Food Chem: 42(1994) https://pubs.acs.org/doi/abs/10.1021/jf00044a016 (pp 1666-1673 26. Amanda Oakley, ‘Hirsutism’ (Hamilton, New Zealand www.dermnetnz.org, 2016) 27. Daisy Kopera and others, ‘Endocrinology of Hirsutism’ Int J Trichology: 2(1) (2010) https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3002408/ (pp30-35) 28. David Ehrmann, ‘Polycystic Ovary Syndrome’ New Eng Journ Med: 36 (2005) https://pedclerk. uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/PCOS.NEJM_.2005.pdf (pp1223-1236) Cited by: Daisy Kopera and others, ‘Endocrinology of Hirsutism’ Int J Trichology: 2(1) (2010) https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3002408/) (pp30-35) 29. Mehmet Akdogan and others, ‘Effect of spearmint (Mentha Spicata Labiatae) Teas on Androgen Levels in Women With Hirsutism’ Phytotherapy Research: 21(5) (2007) https://onlinelibrary.wiley.com/ doi/abs/10.1002/ptr.2074 (pp444-447) 30. Lana Burgess and others, ‘What Are Phytoestrogens? Benefits and Foods?’ (Online) (Brighton, UK www.medicalnewstoday.com) 31. Reijo Punnonen and others ‘Demonstration of Estrogen Receptors in the Skin” J Endocrinol Invest :3 (3) (1980) (pp 217-21) Cited by: Nick Reine-Fenning and others “Skin Aging and Menopause’ Am Journ Clin Dermatol: 4(6) (2003): https://www.researchgate.net/profile/Yves_Muscat_Baron/

publication/10746536_Skin_Aging_and_Menopause/links/576ae27608ae6e772780b507/SkinAging-and-Menopause.pdf (pp 371-378) 32. Nick Reine-Fenning and others “Skin Aging and Menopause’ Am Journ Clin Dermatol: 4(6) (2003): https://www.researchgate.net/profile/Yves_Muscat_Baron/publication/10746536_Skin_Aging_and_ Menopause/links/576ae27608ae6e772780b507/Skin-Aging-and-Menopause.pdf (pp 371-378) 33. Hye-Sun Oh and others, ‘An Estrogen Receptor Pathway Regulates the Telogen-Anagen Hair Follicle Transition and Influences Epidermal Cell Proliferation’ Proc Natl Acad Sci U S A: 93(22)(1996)https:// www.pnas.org/content/pnas/93/22/12525.full.pdf (pp 12525-30) 34. Inger Bjorn, ‘Drug Related Negative Side-Effects is a Common Reason for Poor Compliance in Hormone Replacement Therapy’ Maturitas: 32(2)(1999) https://www.sciencedirect.com/science/article/ abs/pii/S0378512299000183 (pp77-86) 35. Tao Akiyama and others, ‘Genistein, A Specific Inhibitor of Tyrosine-Specific Protein Kinases,’ J. Biol. Chem. 262 (12) (1987) https://www.ncbi.nlm.nih.gov/pubmed/3106339 (pp 5592–5595) 36. Andrea Moraes and others, ‘The Effects of Topical Isoflavones on Postmenopausal Skin: Doubleblind and Randomized Clinical Trial of Efficacy,’ Eur J Obstets & Gynae and Repro Biol: 146(2) (2009) https://www.sciencedirect.com/science/article/pii/S0301211509002553#! (pp 188-192) 37. Yuki Okabe and others, ‘Higher Bioavailability of Isoflavones After a Single Ingestion of AglyconeRich Fermented Soybeans Compared with Glucoside-Rich Non-Fermented Soybeans in Japanese Postmenopausal Women. J Sci Foud Agric 91(4) (2011) https://www.ncbi.nlm.nih.gov/pubmed/21104834 (pp 658-663) 38. Zoe Draelos, ’The Science Behind Skin Care: Moisturizers’ Journ Cosmet Dermatol. 17(2) (2018) https://onlinelibrary.wiley.com/doi/abs/10.1111/jocd.12490 pp 138-144) 39. Kevin Brough and others, ‘Hormonal Therapy in Female Pattern Hair loss’ Int J Womens Dermatol. 2017 Mar; 3(1): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419033/ (pp53-57) 40. Peter Adenuga and others Hair regrowth in a male patient with extensive androgenetic alopecia on estrogen therapy. J Am Acad Dermatol.;67 (3) (2012) https://www.ncbi.nlm.nih.gov/pubmed/22890743 (pp e121–e123) . 41. Daniel Raudrant and others, ‘Progestogens with Antiandrogenic Properties.’ Drugs.63 (5) (2003) https://www.ncbi.nlm.nih.gov/pubmed/12600226 (pp 463–492) 42. Noah Scheinfeld A review of hormonal therapy for female pattern (androgenic) alopecia. Dermatol Online J. 14(3) (2008) https://www.ncbi.nlm.nih.gov/pubmed/18627703 (pp 1) 43. Yi Wang Chang and others, ‘Synbiotics for Prevention and Treatment of AD’ Jama Pediatrics 170(3) (2016) https://jamanetwork.com/journals/jamapediatrics/fullarticle/2481808 (pp236-242) 44. Audrey Gueniche and others, ‘Lactobacillus Paracasei Inhibits Substance P-Induced Skin Inflammation and Accelerates Skin Barrier Function Recovery in Vitro,’ Eur J Dermatol 20(6) (2010) https://www.ncbi.nlm.nih.gov/pubmed/20965806 (pp :731-737) 45. Andrea Parodi ‘Small Intestinal Bacterial Overgrowth in Rosacea: Clinical Effectiveness of its Eradication’. Clin Gastroenterol Hepatol. 6 (2008) 46. Vinayak Gaware and others, ‘The Magic of Kefir: A Review’ Pharmacology Online: 1(2011)https:// pharmacologyonline.silae.it/files/newsletter/2011/vol1/034.gaware.pdf (pp 376-386) 47. Suyun Li and others, (2017) ‘Alcohol Intake and Risk of Rosacea in US Women’ J Am Acad Dermatol 76(6) (2017) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5438297/ (pp 1061-7) 48. Jan Kubo and others, (2014) ‘Alcohol Consumption and Increased Risk of Melanoma and NonMelanoma Skin Cancer in the Women’s Health Initiative’ Cancer Causes and Control;25(1) (2014) https://www.ncbi.nlm.nih.gov/pubmed/24173533 (pp 1-10)

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To book a training session: Call: 0333 358 3904 Email: info@naturastudios.co.uk www.naurastudios.co.uk


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capsule of mainly type I, or non-scar tissue collagen, around each of the particles. This process of encapsulation will last as long as the foreign body or biomaterial remains within the tissues of the body.1,8,9 Multiple factors affect this process of encapsulation of the implanted material, including the site of implantation and the host response, which is dependent on the health status and age of the patient. Equally as important is the physical properties of the Dr Ian Strawford details the use of collagenbiomaterial implanted, notably the size and stimulating fillers and shares a successful case study shape of the particles. Simply put, the effect of a biomaterial on the host is to stimulate In my practice, collagen-stimulating fillers have become an an inflammatory/immune response and the response of the host on increasingly popular treatment choice among patients in the 40-60 the biomaterial is to attempt to eliminate or encapsulate the foreign age group as they offer age appropriate, natural and long-lasting material.1,10 Biomaterial particle size and shape is a significant factor on 1 results with very low risks of complications. predicting the response to the implanted material. Particles less than In this article I will discuss how a collagen-stimulator treatment differs 20mm in size are phagocytosed by macrophages and eliminated from traditional hyaluronic acid-based fillers and how they can be from the body.11 Particle sizes of between 25mm and 50mm and used for facial contouring, volume restoration and skin rejuvenation spherical in shape produce the most fibrosis or new collagen when through bio-stimulation of the tissues. implanted, due to the higher surface area per mass of any biomaterial used.12 Particle sizes greater than 50mm in size are more likely to A rise in popularity produce a prolonged inflammatory reaction, producing only type In recent years the recognition and importance that facial volume loss III collagen.1,11 In essence, a perfect bio-stimulatory material needs plays in the ageing process has shifted the focus of treatment from a to produce a predictable host response when implanted, which in concentration on isolated problem areas, such as the nasolabial folds, the case of collagen-stimulating dermal fillers, is to produce type I to targeting the entire face to restore shape for a more harmonious collagen in response to the biomaterial for as long as it is present and natural effect.2 in the body. Thus, in my professional opinion, the ideal collagenDermal fillers have become a popular means of addressing volume stimulating product used in medical aesthetics should consist of loss and contour defects resulting from ageing, disease or trauma, smooth microspheres no larger than 50mm in size, stable in both size and the most widely used are the ones based on hyaluronic acid and shape, as well as being long lasting, before degradation and full gels.3,4 However, non-permanent collagen-stimulating dermal fillers elimination from the body.1 have become an increasingly important and popular treatment in medical aesthetics.5 Since the introduction of calcium hydroxyapatite Treatment technique and poly-L-lactic acid collagen-stimulating dermal fillers in 2006 Prior to treatment, an aseptic technique should be adopted to and 2004, respectively, the role of collagen stimulation in facial prepare the face. Depending on where you are treating will aesthetics has been extensively studied.5,6 Interestingly, the initial use determine the depth of injection; however, for temple hollowing, of poly-L-lactic acid, was in patients with severe facial lipoatrophy malar volume correction, cheek augmentation and jawline contouring, associated with HIV infection, which was explored in a 2006 literature I would recommend a supraperiosteal injection, placing the product review conducted by El-Beyrouty et al., where results showed that on the bone. More superficial placement can be used to address cutaneous thickness improved in these patients.7 subdermal volume loss and for bio-stimulation, in order to increase collagen and elastin within the dermis. I would recommend that What is the mechanism of action? placement of the product can either be by 27 gauge needle or On injecting any dermal filler or bio-stimulatory agent/biomaterial such 25 gauge cannula. Caution should be taken with older patients who as polycaprolactone into human tissue, there will always be an initial are less likely to respond well. This is because, with age, the number foreign body response in the hostâ&#x20AC;&#x2122;s tissues to the injected product.1 Before After It is important to understand the mechanism of this foreign body response to understand why collagen stimulation occurs and how it is part of the normal healing response of the body. Normal healing starts within two hours of a wound, through an initial inflammatory phase, with the production of macrophage cells, which in turn stimulate fibroblast cells, to produce initially type III collagen or scar tissue.1 This rapid production of type III collagen allows a quick initial healing phase. With an implanted material such as polycaprolactone, following the initial inflammatory phase and within two weeks, the micro-particles within the tissues will become encapsulated by fibroblasts leading to fibroplasia. This is a natural Figure 1: Patient before and 12 weeks after treatment. The result of bioprotective mechanism of the body to isolate the â&#x20AC;&#x2DC;harmfulâ&#x20AC;&#x2122; foreign stimulation will be gradual over the next six months but long lasting, up to particles. This gradual process of encapsulation produces a stable two years.16

Understanding Collagen-stimulating Dermal Fillers

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Conclusion

Figure 2: Polycaprolactone microspheres in Ellansé

of fibroblasts decrease so the regenerative power reduces with age. Patients who smoke are also less likely to respond to treatment and auto-immune diseases, such as inflammatory bowel disease or rheumatoid arthritis, are a contraindication to this treatment.

Side effects and complications As with most dermal filler treatments, bruising and swelling is not uncommon. More serious complications such as delayed onset nodules and inflammation or infection are thankfully very rare. Numerous publications have described the modalities of complications seen with dermal fillers in general and the management and treatment of them.13-15 To my knowledge, there are not any complications that are unique to collagen stimulators that don’t apply to other dermal fillers.

Case Study This 62-year-old patient presented with concerns about volume loss in the malar area, loss of jawline definition and increasing superficial rhytids, especially in the perioral area. She had a full SMAS facelift 15 years previously and other than regular toxin treatments following the facelift, had not had any other non-surgical treatments. Following my assessment, I decided to address the rhytids and treat the malar cheek, marionettes, temple and jawline, while improving skin quality. My product of choice was Ellansé S and Ellansé M. This is because, as previously mentioned, the microspheres in the product are smooth, no larger than 50mm in size and stable in both size and shape (Figure 2). The collagen stimulation following this bio-stimulation reliably shows a volumisation of the hypodermal fat layer with an improvement in dermal thickness and elasticity similar to traditional hyaluronic acid skin boosters, but with results lasting more than two years.16 I mixed 0.2ml of lidocaine 1% or 2% with each 1ml syringe to help with patient comfort during injection. This has been shown to be safe without altering the physical properties of the CMC gel carrier.17 I used a combination of needle and cannula for deep placement of the product supra-periosteal along the mandible to support the mentalis muscle and pre-jowl sulcus and posterior masseter at the angle of the mandible. Each depot bolus or linear thread is no more than 0.1-0.2ml. In this case the total amounts were 1.2ml. To volumise the deep malar fat pad and the suborbicularis oculi fat I will always use a 25 or 23 gauge cannula, placing the product supraperiosteal on the bone. In this case, I used a total on 2ml for both cheeks, 1ml on each side. For the temples I used 0.4ml on each side, placed directly on bone using a 27 gauge needle. The subdermal bio-stimulation technique involves passing a 25 or 23 gauge cannula in the superficial subdermal fat layer, repetitively moving the cannula as a form of subscision to free the superficial dermis, before injecting very small volumes of product, less than 0.05ml per linear thread to cover the area in a multi-vector pattern (cross hatch). This procedure was undertaken over the whole of the lower face, including the lips, using a total of 2ml.

All dermal fillers, whether traditional hyaluronic acid derived or collagen stimulating, induce a foreign body reaction to this ‘implant’, when injected into human tissue, and it is important to understand the biological process that occurs following this. Collagen-stimulating dermal fillers have their long-term effect by producing encapsulation of the product which, if stable, will produce healthy type I collagen and not an inflammatory reaction producing type III scar tissue. In my opinion, the ideal collagenstimulating dermal filler, needs to be smooth and spherical in shape and between 25mm and 50mm in size. In my practice, many patients are seeking natural and long-lasting results and collagen-stimulating fillers have become the main tool I use to achieve these desired outcomes. Disclosure: Dr Ian Strawford is a key opinion leader for Sinclair Pharma, the manufacturer of Ellansé Dr Strawford is a GP and aesthetic doctor with more than 30 years’ experience. He is the medical director of Skin Excellence Clinics with clinics in Devon and Somerset. He is an international trainer and KOL for Sinclair Pharma. Dr Strawford is also a member of the British College of Aesthetic Medicine and The American Academy of Anti-Aging Medicine. REFERENCES 1. NICOLAU, P. J. 2007. Long-lasting and permanent fillers: biomaterial influence over host tissue response. Plast Reconstr Surg, 119, 2271-86. 2. LUPO, M. P. 2008. Natural look in volume restoration. J Drugs Dermatol, 7, 833-9 3. SMITH, K. C. 2008. Reversible vs. nonreversible fillers in facial aesthetics: concerns and considerations. Dermatol Online J, 14, 3. 4. CARRUTHERS, J., CARRUTHERS, A. & HUMPHREY, S. 2015. Introduction to Fillers. Plast Reconstr Surg, 136, 120s-131s. 5. PAVICIC, T. 2013. Calcium hydroxylapatite filler: an overview of safety and tolerability. J Drugs Dermatol, 12, 996-1002. 6. LACOMBE, V. 2009. Sculptra: a stimulatory filler. Facial Plast Surg, 25, 95-9. 7. El-Beyrouty C et al., Poly-L-lactic acid for facial lipoatrophy in HIV, Annals of Pharmacotherapy, September 2006 8. WILLIAMS , D. 2008. On the mechanisms of bioompatability Biomaterials 2941-53. 9. KIM, J. A. & VAN ABEL, D. 2015. Neocollagenesis in human tissue injected with a polycaprolactonebased dermal filler. J Cosmet Laser Ther, 17, 99-101. 10. RATNER, B., BRYANT, S 2004. Biomaterials : Where have we been and where are we going Annu Rev Biomed Eng, 41-75. 11. MORHENN, V. B., LEMPERLE, G. & GALLO, R. L. 2002. Phagocytosis of different particulate dermal filler substances by human macrophages and skin cells. Dermatol Surg, 28, 484-90. 12. GELB,H.E.A 1994 In vivo inflammatory response to polymethylmethacrylate particle debirs:effect of size, morphology and surface area. J.Otop.Res,12. 13. HEPPT, M., HARTMANN, D., REINHOLZ, M., FELLER-HEPPT, G., RUZICKA, T. & GAUGLITZ, G. G. 2015. [Fillers and associated side effects]. Hno, 63, 472-80. 14. BELEZNAY, K., CARRUTHERS, J. D., HUMPHREY, S. & JONES, D. 2015. Avoiding and Treating Blindness From Fillers: A Review of the World Literature. Dermatol Surg, 41, 1097-117. 15. BAILEY, S. H., COHEN, J. L. & KENKEL, J. M. 2011. Etiology, prevention, and treatment of dermal filler complications. Aesthet Surg J, 31, 110-21. 16. OZZO.I, R. R. 2016. Combined use of Suspension Threads and Polycaprolactone filler. The Invisible Facelift - Manual of Clinical Practice 2nd Edition ed. Italy Officina Editoraile Oltrarno 17. DE MELO, F. & MARIJNISSEN-HOFSTE, J. 2012. Investigation of physical properties of a polycaprolactone dermal filler when mixed with lidocaine and lidocaine/epinephrine. Dermatol Ther (Heidelb), 2, 13.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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version 1.0 – July 2019

1. Sito G, et al. Aesthet Surg J. 2019. doi: 10.1093/asj/sjz026. 2. Micheels P et al. J Drugs Dermatol 2017;16(2):154–61.


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The best way to do this is to prevent the need for them in the first place by minimising the risks of infection. If treatment is required, ensure that first line choices are always given, unless contraindicated and that both the practitioner and patient are well educated in the correct use of the drug.

Causes of antibiotic resistance It is generally accepted that the rise in antibiotic resistance is attributed to four main causes: overuse, inappropriate prescribing, agricultural use and fewer new antibiotics on the market.

Considering Antibiotic Resistance in Aesthetics Prescribing pharmacist Gemma Fromage details how aesthetic practitioners can assist in slowing the rate of antibiotic resistance As all medical professionals know, antibiotic resistance is the ability of microbes to withstand the effects of medications. Germs are therefore not killed and as a result of this resistance they continue to grow.1 Since the development of antibiotics, millions of lives have been saved. However, if the rate of resistance continues, as it currently is, it is estimated that there will be 10 million deaths per year by 2050 and take society back to a pre-antibiotic existence.2 According to the World Health Organisation, antibiotic resistance is one of the biggest threats to global health.1 Resistance cannot be stopped, however it can be slowed. Although this needs to be tackled globally, there are steps that individuals and clinics within the aesthetic field can take to reduce infection and, in turn, assist in the reduction of spread of resistance. To prevent infection arising from aesthetic treatments such as dermal fillers or laser treatments, it is important that we keep the numbers of antibiotics we are prescribing, and therefore antibiotics consumed, to a minimum.

Overuse Studies have shown there is a direct link between the overuse of antibiotics and the increasing rates of bacterial resistance.12 Overuse can have many effects; resistance can not only occur spontaneously via mutation, but also antibiotics remove drugsensitive competitors, resulting in resistant bacteria being left behind to reproduce due to natural selection.13 It is well-established that antibiotics are overused worldwide, despite repeated warnings.14 Whilst in the UK, antibiotics are still prescription-only medications, they are freely available over the counter in a number of countries like Norway, Germany, Slovakia and Romania. As such, their use is unregulated with no need for a prescription or to see a medical professional beforehand.14 With no regulation behind their sale and often being both cheap and plentiful, it is inevitable that overuse will occur.15 In addition, with the prevalence of online sales of these products, their

The history of antibiotics The modern era of antibiotics began in 1928 with the discovery of penicillin by Sir Alexander Flemming.3 He then spent years trying to persuade scientists to take an interest in it and it wasnâ&#x20AC;&#x2122;t until 1939 that a team in Oxford, headed by Foley, Heatley and Chain began work with penicillin.4 The first human to be trialled on was Albert Alexander on in February 1941. The treatment was a success, but due to a lack of product to continue treatment he relapsed and died. The problem was producing enough product. So, they headed to America in a bid to industrialise penicillin production. The plan was to have enough penicillin supply for medical support for the planned invasion in Europe. By D-Day, June 6th, 1944, the armies were well stocked with penicillin to treat war wounds. In March 1945, penicillin was made available over the counter in US pharmacies and then available in the UK as a prescription-only drug in June the following year.4 However, within just a decade, resistance was already becoming a problem.5 The discovery and subsequent use of antibiotics has without a doubt been one of the

most significant cornerstones of clinical medicine in the latter half of the 20th century, saving lives, extending life spans6 and playing a key role in both medical and surgical advances.7 In contrast, the last decade of the 20th century and first two decades of the 21st century has seen the spread of antibiotic resistance. Antibiotic resistance is on the rise among many microorganisms in all health-care settings, as well as in the community.8 In 2007 the European Medicines Agency (EMA) and European Centre for Disease Prevention and Control (ECDC) reported 25,000 deaths per year as a direct consequence of multidrug resistance (MDR) with a total cost of â&#x201A;Ź1.5 billion.9 The study was then repeated in 2015 and it was estimated that the number of deaths per year has increased to 33,000.10 Reported data also suggests that almost two million cases of infection with resistant bacteria have been reported in the US every year, leading to $20 billion incremental direct healthcare cost.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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accessibility is increasing even in countries where their usage is regulated, like the UK.15 Inappropriate prescribing Studies have shown that incorrect prescribing of antibiotics, with the indication, choice of agent or duration of treatment being suboptimal, occurs in 30-50% of antibiotic prescriptions.12,16-18 The use of subinhibitory and subtherapeutic antibiotic doses has prompted the development of resistance via gene generic alterations, such as changes in gene expression, horizontal gene transfer and mutagenesis.19 Incorrect prescribing of antibiotics has not only contributed to resistance,12 but it also has questionable therapeutic benefit and leaves patients open to potential complications, such as increased severity of infection, longer hospital stays and mortality.20 Agricultural use Antibiotics are reported to improve both the health of the animal and produce a larger yield and higher-quality product,15 so are commonly used worldwide as growth supplements in livestock.9 As a result, antibiotic use for this purpose in agriculture can potentially lead to the ingestion of antibiotics in humans via the consumption of animal meat.21 As with humans, the use of antibiotics in food-producing animals leads to susceptible bacteria being killed, leaving antibiotic resistant bacteria to thrive. These bacteria can be transmitted to humans through the food supply, leading to infection and ill health.12 Fewer new antibiotics As antibiotics are commonly prescribed for short-term, curable conditions, the development of new antibiotics is no longer considered to be as much of an economical investment22 or as profitable compared to drugs used to treat chronic conditions.21 As such, the search for new antibiotics by pharmaceutical companies has essentially stalled. Any new antibiotic developed would basically be considered a ‘last-line’ agent, reserved for serious illness only.13 This is due to the constant advice that antibiotic usage should be restricted, with any new antibiotics in particular not to be used as a first-line treatment, but held in reserve.21 This means that return on investment is much lower for these drugs8 and with eventual resistance being inevitable, profits will not only be lower, but limited.7

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How aesthetic practitioners can help The fight against antibiotic resistance is a global matter, but I believe that there are steps that both individuals and clinics can take at a local level which will help slow the rate of resistance developing. Appropriate prescribing Empirical antibiotic treatment should be started and the practitioner should consider the clinical presentation of the patient’s condition, the suspected prevalent pathogen and any resistance pattern present locally. Guidelines are available to consult for first and second-line treatments; locally there will be a formulary. The British National Formulary23 also provides guidelines, as do more specialist groups within aesthetics such as the Aesthetic Complications Expert (ACE) Group.24 The ACE Group’s guidelines are to prescribe first-line treatment of flucloxacillin 500mg QDS PO (if penicillin allergic, clarithromycin 500mg BD PO) and for second-line treatment, the prescriber should consider the addition of penicillin, amoxicillin or co-amoxiclav (if penicillin allergic, clindamycin 300mg QDS PO).24 Care must be taken to ensure the patient has no antibiotic allergies and, if they do, that these are taken into consideration when prescribing. First-line treatment of infection is recommended for seven days, however if improvement is slow, it should be continued for a further seven days.25 Patients should be closely monitored and if no response is seen at 48-72 hours then a change in regime should be considered. If available, a swab for microbiology, culture and sensitivity should be taken at this point, which would allow the correct antibiotic needed to be identified. Prescriber education Practitioners should have in-depth knowledge and understanding of infection

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control. It is important that the practitioner is able to thoroughly assess the patient as the start of an infection may be easily confused for the initial reaction to treatment, such as heat, redness and swelling. The risk of necrosis and allergic reaction should always be ruled out before the diagnosis of infection and therefore inappropriate treatment. The practitioner should be confident in selecting an appropriate antibiotic, knowing when to choose an alternative treatment and when to refer for further testing. If a patient requires antibiotics and the practitioner is not a prescriber, then a protocol should be in place to refer to a prescriber confident in dealing with aesthetic complications who can quickly and effectively provide appropriate treatment to the patient with minimal delay. A delay in treatment means more time for the bacteria to develop, multiply and strengthen. Patient education Patients should be informed of and given written aftercare advice relating to the procedure they have undergone on the possibilities of infection and how they can minimise their risk. For example, no makeup for eight hours after treatment and no touching of the area that has been treated for four hours after treatment.17 Patient education is linked to speed of diagnosis and treatment. Patients should also be made aware of signs and symptoms to look out for such as redness, swelling or heat in the area that is not settling over the following 48 hours, as well as systemic symptoms such as fever, malaise or nausea. If patients do require antibiotics, then patient education on compliance is a must. Studies have shown that more than one third of patients were non-compliant to their antibiotic regimen and one quarter kept the unused antibiotics for future use.26-28 The course must be completed regardless of if the patient believes the infection to be

It is generally accepted that the rise in antibiotic resistance is attributed to four main causes: overuse, inappropriate prescribing, agricultural use and fewer new antibiotics

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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The practitioner should be confident in selecting an appropriate antibiotic, knowing when to choose an alternative treatment and when to refer for further testing gone. Conversely, it is also essential that if patients feel an infection is returning, that they make their practitioner aware of the situation. Aseptic non-touch technique At the core of the aseptic non-touch technique (ANTT) framework is the aim of asepsis; an accurate and achievable quality standard relating to the absence of pathogenic microorganisms.29 ANTT is achieved by ensuring the asepsis of key parts and sites of the procedure. Better defined, the infection control methods and precautions necessary during invasive clinical procedures to prevent the transfer of microorganisms from health professionals, equipment or the immediate environment to the patient. Studies have shown that a number of infections are caused due to failed aseptic techniques, especially in procedures that breach patients’ natural defence mechanisms.30 With regard to healthcareassociated infections, aseptic technique can be seen as the most common and critical infection prevention practice in healthcare.30 Some pointers for best practice include: • Identifying and protecting key parts and key sites (i.e. clinical equipment that comes into contact with the patient and the areas on the patient of which the protective skin barrier is broken) • Non-touch technique is the most important component of ANTT, as the safest way to protect a key part is to not touch it • Ensuring the highest level of hygiene is adopted (i.e. clean surfaces, clean environment, clean disposal, clean hands, gloves) • Educating your patient to not touch the areas for the hours following the treatment, not to apply make up for the rest of the day etc. • Ensure you have access to your local

guidelines or are a member of ACE Group and have access to their guidelines for treatment • Be confident in identifying infection and knowing what to prescribe and when to change antibiotic regime if necessary • If you are not a prescriber, ensure you have quick access to a local prescriber who is confident in the above and can prescribe if necessary Infections can unfortunately occur following any treatment that involves breach in the skin’s integrity. In most case this follows needle trauma to skin during injectable treatments such as toxin or fillers, but in some cases may occur following non-penetrating treatments such as chemical peels or laser procedures. The rates of infection following dermal filler are low, estimated at 0.04-0.2%, although many may not be reported, and risk and can be attributed to several factors.25

Conclusion Antibiotic resistance is a complex problem with a variety of contributing factors. The spread of resistance cannot be stopped but it can be slowed. Unfortunately, it is not a problem that can be solved by individual groups or countries and must be tackled universally. Joint efforts are required from both patients and practitioners, to international policy makers.

REFERENCES 1. WHO, Antibiotic resistance, February 2018 <https://www.who.int/ news-room/fact-sheets/detail/antibiotic-resistance> 2. O’neill J, Tackling drug-resistant infections globally, Amr-review. org, 2016, <https://amr-review.org/sites/default/files/160525_ Final%20paper_with%20cover.pdf> 3. Sengupta S, Chattopadhyay MK, Grossart HP, The multifaceted roles of antibiotics and antibiotic resistance in nature, Front Microbiol, 2013 4. STMU History Media, Fleming, Chain, Florely and Heatley: The minds behing the discovery of penicillin, May 2019 <https:// stmuhistorymedia.org/fleming-chain-florey-and-heatley-theminds-behind-the-discovery-of-penicillin/> 5. Spellberg B, Gilbert DN, The future of antibiotics and resistance: a tribute to a career of leadership by John Bartlett, Clin Infect Dis, 2014 6. Rossolini GM, Arena F, Pecile P, Pollini S. Update on the antibiotic resistance crisis, Curr Opin Pharmacol, 2014 7. Gould IM, Bal AM, New antibiotic agents in the pipeline and how they can help overcome microbial resistance, Virulence. 2013 8. Piddock LJV, The crisis of no new antibiotics—what is the way forward? Lancet Infect Dis, 2012 9. ECDC/EMEA Joint Technical Report, The bacterial challenge: time to react. European Centre for Disease Prevention and Control, 2009. EMEA. doc. ref. EMEA/576176/2009 10. Cassini A et al., Attributable deaths and disability adjusted life years caused by infections with antibiotic resistant bacteria in the EU and the European Economic rea in 2015, The Lancet, 2018 11. Antibiotic Resistance Threats in the United States, US Department of Human and Health Services, Centre for Disease Control and prevention, 2013 12. Centers for Disease Control and Prevention Office of Infectious Diseases, Antibiotic resistance threats in the United States, 2013 13. Read AF, Woods RJ. Antibiotic resistance management, Evol Med Public Health, 2014 14. Nature, The antibiotic alarm, Nature. 2013 15. Michael CA, Dominey-Howes D, Labbate M. The antimicrobial resistance crisis: causes, consequences, and management, Front Public Health, 2014 16. Centers for Disease Control and Prevention, Office of Infectious Disease Antibiotic resistance threats in the United States, April 2013 17. Luyt CE et al., Antibiotic stewardship in the intensive care unit, Crit Care, 2014 18. Swami O et al., Strategies to Combat Antimicrobial Resistance, Journal of clinical and diagnostic research, 2014 19. Viswanathan VK, Off-label abuse of antibiotics by bacteria. Gut Microbes, 2014 20. Lushniak BD, Antibiotic resistance: a public health crisis, Public Health Rep. 2014 21. Golkar Z, Bagasra O, Pace DG, Bacteriophage therapy: a potential solution for the antibiotic resistance crisis, J Infect Dev Ctries, 2014 22. Bartlett JG, Gilbert DN, Spellberg B, Seven ways to preserve the miracle of antibiotics. Clin Infect Dis. 2013 23. British National Formulary, <bnf.nice.org.uk> 24. The Aesthetics Complications Expert Group <https://acegroup. online/> 25. Ferneini, E et al., An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment, Journal of Oral and Maxillofacial Surgery, 2017 26. Kardas P et al., A systematic review and meta-analysis of misuse of antibiotic therapies in the community. International Journal of Antimicrobial Agents. 2005 27. Fernandes M et al., Non-adherence to antibiotic therapy in patients visiting community pharmacies. International Journal of Clinical Pharmacy, 2013 28. Axelsson, M. Report on personality and adherence to antibiotic therapy: a population-based study, BMC Psychology, 2013 29. Hauswirth K, Sherk SD, Aseptic Technique, Encyclopedia of Surgery, 2013 30. Nursing Times, ANTT: a standard approach to aseptic technique, Nursing Times, 2019

Gemma Fromage is a prescribing pharmacist and received her Master’s in Pharmacy in 2006. She started working in the aesthetics industry in 2010 and now runs her own clinic, Your Skin Health in Raynes Park.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Practising Hypnotherapy in Aesthetics Dr Kathleen Long explores the use of hypnosis for needle phobia and pain in aesthetic patients If you ask what hypnosis is, you may get a variety of different answers. Often, it’s thought of as some sort of ‘mind control’ where the hypnotist directs the person to change and overrides their free will. Others think that hypnotherapy is for entertainment purposes only at the local theatre. What most patients and clinicians alike don’t seem to know is that hypnosis can be effective in pain relief and even phobias, which are issues commonly seen in aesthetic practice.1-3 This article aims to help practitioners understand the possibilities of hypnosis in an aesthetic setting, and to update you on a service that could be valuable to your patients.

What is hypnosis? Defining hypnosis, to this day, is still a matter of some controversy. Hartland’s Medical and Dental Hypnosis is a well-known book or ‘bible’ that discusses 10 different explanations for the nature and theory of hypnosis.4 According to The European Hypnosis Society, which is supported by 14,000 doctors, dentists, psychiatrists, psychologists and psychotherapists, hypnosis is a ‘Communication method that allows a person to enter an altered state of consciousness’ and is a ‘State of altered awareness promoting enhanced concentration and allowing a deepened relaxation to be experienced at the same time. During the hypnotic induction, awareness is gradually directed from the outer world to the inner world, and it becomes considerably easier to focus on significant aspects of the inner world in a relaxed, mindful manner’.4,5 The effectiveness of hypnosis is well established. The British Medical Journal (BMJ) has recent publications confirming that cognitive behavioural hypnotherapy was 70% more effective than cognitive behavioural therapy on its own in both outcomes and longterm remission in a meta-analysis of 18 studies.6,7 The BMJ has also credited the success of hypnosis in some of the most treatment-resistant psychiatric disorders such as phobias, body dysmorphic disorder, eating disorders and substance abuse, as well as demonstrating success in helping people with low self-esteem and motivational issues.8

How does hypnosis work? There are different types of hypnotherapy and different ways of hypnotising someone, which are too complex to be discussed in detail. The common techniques are relaxation and focused attention techniques, however hypnosis uses a plethora of other techniques such as ego strengthening, confusion, dissociation, distraction, reframing, future pacing, metaphors, therapeutic storytelling and anchoring.9-12

Through the hypnotherapy technique, the hypnotherapist may (but not always) lead the patient into a deeply relaxed state or ‘trance’. When they are in a trance, they are very relaxed, have an altered sense of reality and have a distorted sense of time. The hypnotherapist will then normally suggest ways to help the patient towards achieving their goals while they are in this trance, and then gradually bring the patient out of the relaxed state.13 One of the factors in hypnotic trance is time distortion. Have you ever driven to work on your day off? Have you ever gone by an exit you meant to take on the motorway? Do you daydream and wonder where the time has gone? These are all examples of trance usually with time distortion and deletion. When I say deletion, I mean ignoring all the other things going on around you while your focus is elsewhere. The simple truth is that hypnosis is a natural state and we go in and out of trance automatically and frequently every day without realising it.14 This car example is known as ‘wide awake trance’ because you are still able to do conscious things like drive without crashing. Research has shown that hypnosis activity occurs in the anterior cingulate cortex, superior frontal cortex and thalamus.15,16 There is research that shows changes in electroencephalography brain-wave patterns during the trance state no matter how ‘deep’ and these changes can vary depending on whether the person goes into a deep trance (highly hypnotisable) or a very light trance (low hypnotisable).17 Hypnosis involving a trained professional and a patient involves teamwork where there must be trust, good rapport and a common goal to improve the life of the patient. Only in these conditions will therapeutic hypnosis be successful.

Hypnotherapy for pain Altering perception of pain is one of the most common uses of hypnosis and research is available to substantiate its use for pain relief in burns, surgery and many other situations.18-20 A 2019 systematic review and meta-analysis of 85 controlled experimental trials, consisting of 3,632 participants, suggested that hypnotic intervention can deliver meaningful pain relief for most people and therefore may be an effective and safe alternative to pharmaceutical intervention. However, authors did note that more high-quality data is needed to establish generalisability chronic pain populations.21 Personally, I have used hypnosis to control my pain for both during and after two caesarean sections rather than opting for

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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pain-relief medication. A methodological review on the efficacy of hypnosis for reducing labour and delivery pain, using 13 relevant studies, suggested hetero-hypnosis and self-hypnosis were consistently shown to be more effective than standard medical care, supportive counselling, and childbirth education classes in reducing pain.22 I also had an endometrial polyp biopsied under self-hypnosis when this would have normally involved general anaesthetic.23 Aesthetic patients are usually not subject to extreme pain. However, everyone has a different level of pain threshold and perception of pain, so hypnosis techniques can be useful for those who are more susceptible. They can also be useful for those who do not believe in pain relief and would rather not have anaesthetic before their dermal filler, for example. I have treated a lady’s pain using ‘the glove hand anaesthesia technique’.24,25 This technique involves an initial hypnosis session where the patient is given a simple suggestion that they can cool their hand down at any time they want to so that it becomes numb. You then suggest that the patient can transfer that numbness to any part of their body. In this case, it was the patient’s lips and consequently she had her lip injections done with no anaesthetic injection or cream and no pain. She now ‘freezes’ her lip before she comes in for treatment. This technique can be useful for any injection, particularly in botulinum toxin treatment for hyperhidrosis of the palms of hands and soles of feet, which are very difficult and painful to anaesthetise.

Hypnotherapy for needle phobia Hypnosis has been successfully used for those suffering from phobia, such as flying phobia,26 tocophobia,27 dental phobia and needle phobia.29-32 I often address issues surrounding needle phobias with hypnosis and it’s usually an easy solution. Phobic patients are able to suspend normal critical and logical processing and believe that something, often quite non-threatening, can be terrifying. Most phobias are complex, but have similarities in that the phobia is a symptom of underlying issues which can be, but not always, rooted in traumatic experiences, which may have occurred many years before and sometimes without any conscious memory.33 For needle-phobic patients, I find hypnosis can be useful when combined with the ‘breaking state’ technique from neuro-linguistic programming.34 The idea is to get the patient out of the negative state of worrying about the needle and

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into another state. It’s a distraction and dissociation hypnosis technique. In my experience, this technique only works if you have built good rapport with the patient. It might involve telling the patient a story that contains a lot of detail and often humour for them to process, which can in fact put them into a very light trance where they are wide awake, similar to the car driving example. If it has worked, they will be deleting everything else that’s going on around them and focussing their attention on one thing, which is the story or metaphor and not their needle phobia.35

Training Of course, like anything, you should seek training in hypnotherapy before using on your patients. The British Society of Clinical and Academic Hypnosis and the Royal Society of Medicine runs a certificated course for doctors, dentists and nurses.36,37 The British Society of Medical and Dental Hypnosis Scotland, also run courses on hypnosis.38 Alongside this, I have undergone training in neuro linguistic programming, and this has been an extremely useful addition to my hypnosis training.

Summary Hypnotherapy can be used as an alternate therapy in many parts of your clinical practice as well as your personal life. I have found that it’s an especially useful tool for pain management and needle phobia and is something that I use regularly in my practice. Dr Kathleen Long qualified in 1976 and currently works as a locum GP and aesthetic practitioner. She is the president of the British Medical and Dental Hypnosis Society (Scotland) and president elect of the European Hypnosis Society. She is a Master Practitioner in neurolinguistic programming and has trained doctors in hypnosis in the UK and abroad. Dr Long is also a member of the British College of Aesthetic Medicine and is on the board of directors. REFERENCES 1. Hypnosis and pain research (hypnotic analgesia research), 2019. <https://hypnosisandsuggestion.org/pain-research.html> 2. T Adachi, et al., A Meta-Analysis of Hypnosis for Chronic Pain Problems: A Comparison Between Hypnosis, Standard Care, and Other Psychological Interventions, International Journal of Clinical and Experimental Hypnosis, November 2013, 62(1):1-28. 3. Chapman, Robin A. (Ed). The Clinical Use of Hypnosis in Cognitive Behavior Therapy: A Practitioner’s Casebook. (pp. 101-137). New York, NY: Springer Publishing Co. 4. Michael Heap, Hartland’s Medical and Dental Hypnosis, January 1st 2002, Churchill Livingstone 5. Hypnosis facts, European Society of Hypnosis. <http://eshhypnosis.eu/hypnosis-facts/> 6. Jesper Enander et al., Therapist guided internet based cognitive behavioural therapy for body dysmorphic disorder: single blind randomised controlled trial, BMJ, 2016;352:i241. 7. Susan Mayor, Simpler psychological treatment is as effective as CBT for depression and is cheaper, study shows, BMJ, 2016;354:i4114 8. Edo Shonin, et al., Does mindfulness work?, BMJ,

2015;351:h6919 9. Michael Heap & Kottiyattil K. Aravind, Hartland’s Medical and Dental Hypnosis, 25 Oct 2001. 10. Jeffrey Zeig, Evocation: Enhancing the Psychotherapeutic Encounter (with transcripts and cases of Milton H. Erickson, The Milton H. Erickson Foundation Press, 2019. 11. Shawn Marie Howe, Metaphor Stories for Hypnosis: Stimulate Change While Telling a Tale, 2011. 12. Andy Smith, Practical NLP 4: Submodalities And Anchoring, Coaching Leaders, 2015. 13. NHS, What is Hypnotherapy? 2018. <https://www.nhs.uk/ conditions/hypnotherapy/> 14. Ivan Tyrrell, The uses and abuses of hypnosis, Human Givens Institute. <https://www.hgi.org.uk/resources/delve-ourextensive-library/ethics/uses-and-abuses-hypnosis> 15. The neuroscience of hypnosis: Neuroimaging (brain scanning) studies of hypnosis. <https://hypnosisandsuggestion.org/ neuroscience.html> 16. Müller, K., Bacht, K., Schramm, S., Seitz, R. J. (2012). The facilitating effect of clinical hypnosis on motor imagery: An fMRI study. Behavioural Brain Research, 231, 164-169. 17. De Pascalis V, Perrone M. EEG asymmetry and heart rate during experience of hypnotic analgesia in high and low hypnotizables. Int J Psychophysiol. 1996 Feb-Mar;21(2-3):163-75. 18. Hoosier Hypnosis, Indiana Conserge Hypnosis Services, Pain Research and Hypnosis, <https://hoosierhypnosis.com/2017/10/ pain-research-hypnosis/> 19. Lang, E. V., et al. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. The Lancet, 355, 1486-1490. 20. Elkins, G, et al., Hypnotherapy for the Management of Chronic Pain, Int J Clin Exp Hypn. 2007 Jul; 55(3): 275–287. 21. Thompson, T, et al., The effectiveness of hypnosis for pain relief: A systematic review and meta-analysis of 85 controlled experimental trials, Neurosci Biobehav Rev. 2019 Apr;99:298310. 22. Landolt AS, Milling LS. The efficacy of hypnosis as an intervention for labor and delivery pain: a comprehensive methodological review. Clinical Psychology Review 2011; 31(6): 1022-1031 23. Montgomery GH, DuHamel KN, Redd WH, A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? Int J Clin Exp Hypn 2000; 48: 138-153 24. Michael Heap & Kottiyattil K. Aravind, Hartland’s Medical and Dental Hypnosis, Churchill Livingstone; 4 edition, 2001. 25. Gebhart GF, Schmidt RF, Glove Anesthesia, Encyclopedia of Pain. Springer, Berlin, Heidelberg, 2013. <https://link.springer. com/referenceworkentry/10.1007/978-3-642-28753-4_200886> 26. Spiegel D, Hypnotic responsivity and the treatment of flying phobia, Am J Clin Hypn. 2015;57(2):156-64. 27. Williamson M & Gregory C, Hypnotherapy: the salutogenic solution to dealing with phobias, Pract Midwife. 2015 May;18(5):35-7. 28. Cyna AM, et al., Brief hypnosis for severe needle phobia using switch-wire imagery in a 5-year old, Paediatr Anaesth. 2007 Aug;17(8):800-4. 29. Simon EP & Canonico MM, Use of hypnosis in controlling lumbar puncture distress in an adult needle-phobic dementia patient, Int J Clin Exp Hypn. 2001 Jan;49(1):56-67. 30. Lu DP & Lu GP, Clinical management of needle-phobia patients requiring acupuncture therapy, Acupunct Electrother Res. 1999;24(3-4):189-201. 31. Halsband U, Wolf TG, Functional changes in brain activity after hypnosis in patients with dental phobia, J Physiol Paris. 2015 Dec;109(4-6):131-142. 32. Ferdeghini R, et al., Hypnotic approach during dental treatment: analysis of descriptive data of a case series., J Biol Regul Homeost Agents. 2018 Jan-Feb;32(2 Suppl. 1):67-71. 33. Human Givens Institute, Treatment for dealing with PTSD, Trauma and Phobias. <https://www.hgi.org.uk/usefulinformation/treatment-dealing-ptsd-trauma-phobias> 34. Hypnosis Motivation Institute, ‘NLP Phobia Helping Clients Overcome Phobias, Fears, Past Traumatic Experiences’, American Hypnosis Association <https://hypnosis.edu/aha/ articles/nlp-phobia> 35. NLP, Hypnotherapy Directory, <https://www.hypnotherapydirectory.org.uk/content/nlp.html#nlpandhypnotherapy> 36. British Society of Clinical and Academy Hypnosis. <https://www. bscah.com/> 37. The Royal Society of Medicine, <https://www.rsm.ac.uk/rsmsections/hypnosis-psychosomatic-medicine-section/> 38. British Society of Medical & Dental Hypnosis (Scotland), Aims and Objectives of the BSMDH (Scotland) <http://www. bsmdhscotland.com/>

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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clear. Also, her sibling had recently commented that the appearance of her skin was worsening, which prompted her to seek treatment with me. The consultation revealed that she had a limited budget and that she did not wish to have the downtime associated with conventional chemical peeling due to work commitments. Following her assessment, I diagnosed PIH secondary to acne. I explained in detail about the causes of acne and hyperpigmentation at a cellular level, as I often find that understanding this aids compliance with the Dr Simi Adedeji treats a patient’s concerns subsequent skincare routine and therefore helps in while factoring in a budget achieving optimal results. An important part of the consultation was managing patient expectations The treatment of acne and hyperpigmentation can pose a with regards to what could be achieved, depending on whether particular challenge in many patients, more so in skin of colour the pigmentation was epidermal or dermal. Usual methods of where the tendency to form hyperpigmentation is greater.1 Without determining this include stretching the skin to observe for lightening appropriate precautions, attempts to treat the hyperpigmentation of the pigmentation or using Wood’s lamp; however, I have found that may inadvertently worsen the condition. It is estimated that by 2050, Wood’s lamp is not effective in differentiating between dermal and nearly one half of the US population will have skin of colour.2 epidermal pigmentation in Fitzpatrick type VI skin. According to the last UK consensus in 2011, 40.2% of residents Because of the history of how the pigmentation developed, my in London identified as non-white,3 and 14% of the population in findings on examination of her skin, combined with my professional England and Wales is non-white. As the incidence and prevalence of experience of treating previous similar patients, I classed her post-inflammatory hyperpigmentation (PIH) is likely to continue to rise pigmentation as predominantly epidermal. In my experience, this it is important that aesthetic professionals, especially in and around type of hyperpigmentation is much more responsive to chemical London, understand how to treat PIH effectively. resurfacing or peels than dermal pigmentation, which may require Hyperpigmentation, especially when it affects the face, has a different interventions such as laser for effective treatment.7 social stigma attached to it and can cause the sufferer significant Before treatment it was vital that my patient understood that the psychological distress as it can take years to resolve,1 thereby treatment was a journey, rather than a one-off intervention. impacting on confidence and quality of life.4 Additionally, by the time a patient approaches an aesthetic Pre treatment practitioner for help with this condition, they will usually have used Taking into account the patient’s budget and preference of minimal numerous over-the-counter products at a considerable expense, peeling, I created a personalised treatment plan which consisted of a so their trust and confidence is at a low. It is therefore important to course of chemical skin resurfacing using gentle combination acids, be able to treat PIH correctly and effectively. A standard approach supported by a homecare regime. As requested by the patient, the would likely be chemical peel treatments, but as the patient wanted skin will not experience the level of peeling associated with traditional to specifically avoid this, the case study describes the treatment of chemical peels from this treatment. acne and PIH in skin of colour, using non-hydroquinone products I recommended a course of six treatments performed two weeks and skin-resurfacing acids. apart in clinic; however, for budgeting reasons we revised this and spaced the treatments out so that they were four weeks apart.

Case Study: Treating Acne and Hyperpigmentation

Patient presentation My 27-year-old female patient with Fitzpatrick skin type VI presented to clinic complaining of acne scarring. At the time, she was wearing makeup and no obvious acne scarring was visible. When she returned for her formal consultation, she attended without makeup and it was clear that the scarring she was describing was in fact hyperpigmentation. During the consultation, we discussed and prioritised her areas of concern, how the condition affected her emotionally, her aesthetic goals and any previous treatments she had tried. She described suffering from acne breakouts, which left dark marks on her skin including a line of pigmentation across her nose (known as the allergic salute sign), from habitually rubbing her nose.5,6 These marks were her primary concern and they were extremely dark compared to her normal skin tone. She had previously tried numerous over-the-counter products and a chemical peel at another aesthetic clinic, which had not helped. During the consultation, I noticed that she seemed embarrassed by her skin and maintained poor eye contact. Her main concern was that the blemishes were lasting a long time (months to years) and that she was developing new spots before the blemishes had time to

Hyperpigmentation, especially when it affects the face, has a social stigma attached to it and can cause the sufferer significant psychological distress

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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After

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Figure 1: 27-year-old patient before and after six treatments. Products used included: pHformula, Cliniccare, Déesse Pro and Clinisept Plus.

As she was a Fitzpatrick skin type VI, I advised my patient to prepare her skin with a tyrosinase inhibitor for at least two weeks before we started her first skin-resurfacing treatment. I also started her on a morning and evening homecare regime to maintain and enhance her results. Her morning regime consisted of a gentle exfoliating cleanser containing lactobionic acid, papain enzyme and urea, a serum containing a tyrosinase inhibitor and other combination acids including salicylic acid, an oil-free moisturiser containing niacinamide and strict sun protection (SPF 30) use, with instructions to reapply every two hours if she was outdoors. Her evening regime consisted of the gentle exfoliating cleanser followed by a serum containing a mixture of alpha, beta and poly acids, with 0.1% retinol and finally the oil-free moisturiser containing niacinamide.

Clinic treatment Following two weeks of skin preparation, we began the in-clinic treatment by addressing the acne using a combination of salicylic acid and incorporating LED light treatment on the blue setting to target the Propionibacterium acnes (P.acnes) bacteria that are often implicated in acne formation.8,9 Following successful treatment of her acne, I then moved on to treating the hyperpigmentation using a clay mask formulation containing a combination of acids:

• Mandelic acid and azelaic acid: tyrosinase inhibitors to decrease melanin production10 • Salicylic acid: effective keratolytic for better penetration of acids11 • Retinol: stimulates epidermal cell turnover, which decreases contact between melanocytes and keratinocytes and also helps with removal of already formed pigmentation12 • 4-n-butylresorcinol: tyrosinase inhibitor to decrease melanin synthesis13 I cleansed and degreased the skin before the clay mask and applied a timed pre-resurfacing solution, which allowed me to assess her skin sensitivity and also to prep her skin for better penetration of the combination acids described above. The prepping solution contained the alpha hydroxyl acids lactic acid, mandelic acid and glycolic acid, which help to break down the desmosomal bonds holding stratum corneum keratinocytes together.14,15 After confirming that she would tolerate the treatment well, I applied the mask to her face in a thin layer to allow the skin underneath to be visible so I could watch for any signs of excessive redness or frosting, which are the clinical endpoints of the treatment.16 The mask was removed after 20 minutes. I followed each resurfacing treatment with the application of L-ascorbic acid and a calming mask. On a couple of occasions, there seemed to be excessive erythema of my patient’s skin post treatment; therefore, I used a sheet mask specially formulated with ingredients such as 4% niacinamide and panthenol (anti-inflammatory) to help calm her skin and to avoid overstimulating her melanocytes. I needed to customise each of her six resurfacing treatments according to the condition and response of her skin on that day. This included the use of an activated charcoal peel-off mask and on one occasion, as her skin was quite sensitive, I was unable to perform an acid resurfacing treatment and instead opted for a fruit enzyme ‘peel’ for its gentle exfoliating effects. After I became used to working on her skin and understood how it behaved, I was able to enhance her results by spot treating her areas of hyperpigmentation individually, prior to applying a full-face mask, ensuring that the skin’s exposure to the acids did not exceed the times specified by the protocol.

Post treatment My post-treatment advice included staying off her homecare actives (retinol and tyrosinase inhibitors) until her skin stopped flaking and any erythema subsided (typically two to five days). I also

The consultation revealed that she had a limited budget and that she did not wish to have the downtime associated with conventional chemical peeling

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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implemented mandatory sun protection with SPF 30+ as some of the products used, such as retinol, increase skin sensitivity to UV radiation and also due to the need to block UV radiation mediated melanogenesis.17,18 Follow-up consultations were arranged every four weeks after the treatment with an open appointment given for the patient to contact me should she have any concerns or queries before the four weeks. At the follow-up, we discussed the patient’s experience of her treatment journey, if she noticed any improvement in her pigmentation and/or any side effects. Common side effects she experienced included dryness of the skin, which responded well to the moisturiser in her homecare regime, and some initial flaking of the skin. I also checked her compliance with her homecare regime and sunscreen use, as well as ensuring she was using adequate quantities to achieve visible results.

Challenges As mentioned, the first challenge that occurred was determining if her PIH was epidermal or dermal. Erythema is also not so easily detected in type VI skin, so it is extremely important to frequently ask the patient about their sensitivity level using a sensitivity scale (I used a scale of 1-10 with 1 being no sensitivity or heat and 10 being the most extreme sensation). It’s also important to compare the patient’s treated skin with areas where the mask has not been applied, such as the eyelids, to help detect redness. A patient’s budget can often present a challenge for the practitioner to be able to offer maximum results. For my patient, I managed this by selecting the highest impact ingredients, combined with those that worked in synergy with them, whilst also increasing the interval between resurfacing treatments from two to four weeks. This allowed my patient to spread the cost of the treatments across a few months. Another challenge was not being able to progress to the highest strength clay preparation which, according to the resurfacing protocol used, is not recommended in type V or VI skin. When treating skin that is prone to hyperpigmentation, I find that ‘strongest’ is not always best and that a gentle approach is preferable. I was still able to enhance the results by combining her treatment with other forms of exfoliation such as enzyme peels, retinol and preresurfacing solution to avoid excessive irritation of the skin, which could have worsened her PIH.

Results My patient saw visible results from her first treatment. That night, she noticed that her pigmentation was darker, which caused her initial anxiety and required reassurance. It helped that she knew to expect this as it was discussed in our consultation. Her skin experienced some mild flaking from two to five days post treatment, which she covered with makeup. After the flaking, she noticed that the skin underneath was brighter and less pigmented. Her pigmentation and acne improved with each subsequent treatment. Interestingly, after her third treatment, she felt that she was no longer seeing any improvement in her skin because she was no longer experiencing flaking. In my experience, this is a common misconception; that if visible peeling or flaking does not occur, then the treatment has not been successful. It is also quite common for patients to grow accustomed to their clearer skin and to forget what it looked like previously because the results occur gradually over time. I managed this by exploring these observations with my patient and by sending her progress pictures, which clearly showed significant

improvement in her PIH and helped to improve her trust in the process, while encouraging her to persevere with her treatment plan. By the end of her sixth treatment, the patient’s PIH had improved dramatically from severe to barely visible and she was extremely satisfied with her results. She was particularly pleased that she achieved her aesthetic goal of being able to go out without makeup and her results had been noticed and commented on by friends, work colleagues and family.

Summary Treating PIH in darker skin tones can be challenging, but it is also extremely rewarding as it can have a significant impact on the patient’s self-esteem. It is first necessary to treat the cause of the PIH to break the cycle of inflammation influencing it. It is possible to achieve significant lightening and even resolution of PIH in type VI skin using non-hydroquinone products, combined with chemical peels or chemical skin-resurfacing treatments. Prepping of the skin is strongly recommended for type IV, V and VI skin to avoid worsening the hyperpigmentation. Working within budget constraints can add a further challenge and it is important for practitioners to be able modify their treatment plans to accommodate this. Dr Simi Adedeji graduated from Imperial College London with a Bachelor of Medicine, Bachelor of Surgery and Bachelor of Science. She is a former surgeon, working now as a GP partner and aesthetic practitioner. She has more than 13 years’ post graduate medical experience and is the founder and medical director of Dr Simi Medical Aesthetics. She has a special interest in treating skin of colour and also has a diploma from the faculty of sexual and reproductive health. REFERENCES 1. N.A. Vashi and R.V. Kundu, ‘Facial hyperpigmentation: causes and treatment’, British Journal of Dermatology, 169 (2013), 41-56 2. An Older and More Diverse Nation by Midcentury (USA; U.S. Census Bureau, 2008. <http://www. census.gov/newsroom/releases/archives/population/cb08-123.html> 3. Regional ethnic diversity (London; GOV.UK, 2018) <https://www.ethnicity-facts-figures.service.gov.uk/ uk-population-by-ethnicity/national-and-regional-populations/regional-ethnic-diversity/latest > 4. Balkrishnan R et al, ‘Correlates of health-related quality of life in women with severe facial blemishes’ International Journal of Dermatology 45 (2006), 111–115 5. Myers WA, ‘The “nasal crease”. A physical sign of allergic rhinitis’, Journal of the American Medical Association, 174(1960), 1204-6. 6. Ramot Y et al, ‘Atypical “allergic crease”’.Journal of Dermatological Case Reports, 4(3) (2010), 36-7. 7. M.K. Trivedi et al, ‘A review of laser and light therapy in melasma’ International Journal of Women’s Dermatology, 3(1) (2017), 11–20. 8. Boyd JM1 et al, ‘Propionibacterium acnes susceptibility to low-level 449 nm blue light photobiomodulation,’ Lasers Surg Med 51(8), (2019), 727-734 9. Dai T et al, ‘Blue light for infectious diseases: Propionibacterium acnes, Helicobacter pylori, and beyond?’, Drug Resist Updat 15(4), 2012, 223-36 10. Breathnach AC et al, ‘Azelaic acid therapy in disorders of pigmentation’, Clinics in Drmatology 7(2) (1989) 106-19 11. Arif T, ‘Salicylic acid as a peeling agent: a comprehensive review’, Clinical,Cosmetic and Investigational Dermatology, 8 (2015) 455-61 12. Chapellier B et al, ‘Physiological and retinoid- induced prolifrations of epidermis basal keratinocytes are diferently controlled, 21(13), (2002), 3402-13 13. Lee SJ et al, ‘4-n-butylresorcinol enhances proteolytic degradation of tyrosinase in B16F10 melanoma cells’,Int International Journal of Cosmetic Science, 39(3) (2017), 248-55. 14. AFartasch M et Al, ‘Mode of action of glycolic acid on human stratum corneum: ultrastructural and functional evaluation of the epidermal barrier’, Archives of Dermatological research, 289(7) (1997), 404-9 15. Berardesca et al, ‘Alpha hydroxyacids modulate stratum corneum barrier function’, The British Journal of dermatology, 137(6) (1997), 934-8 16. Khunger N, ‘Standard guidelines of care for chemical peels’, Indian Journal of Dermatology Venereology and Leprology. 74, (2008), Suppl:S5-12. 17. Martini APM, Maia Campos, ‘Influence of visible light on cutaneous hyperchromias: Clinical efficacy of broad-spectrum sunscreens’ Photodermatology, Photoimmunology & Photomedicine., 34(4), (2018), 241-248 18. Dr Michelle Rodrigues, A-Z of Skin: Post-inflammatory hyperpigmentation (Australia: The Australasian College of Dermatologists <https://www.dermcoll.edu.au/atoz/post-inflammatory-hyperpigmentation> 19. Deo KS et al, ‘Kojic acid vis-a-vis its combinations with hydroquinone and betamethasone valerate in melasma: A randomized, single blind, comparative study of efficacy and safety’, Indian Journal of Dermatology, 58 (2013), 281-285 20. Rashmi Sarkar et al, ‘Cosmeceuticals for hyperpigmentation: What is available?’, Journal of Cutaneous and Aesthetic Surgery, 6 (2013), 4-11 21. Sang Yeul Lee et al, ‘Natural, semisynthetic and synthetic tyrosinase inhibitors’, Journal of Enzyme Inhibition and Medicinal Chemistry, 31 (2016), 1-13 22. Kumari S et al, ‘Melanogenesis Inhibitors,’ Acta Dermato Venereologica. 98(10), (2018), 924-931

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


C A S E S T U DY

The secret to beautiful lips ™ lips The secret to beautiful with Restylane Kysse Thesecret secret to beautiful lips ™ The to beautiful lips with Restylane Kysse with Restylane Kysse™ ™™ with Restylane Kysse with aesthetic nurse to practitioner, Sharon Bennett The secret beautiful lips with Restylane Kysse™ C AAdvertorial S E S T U DY Galderma

@aestheticsgroup

@aestheticsjournaluk

Aesthetics

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CCAASSEE SSTTUUDDYY

with aesthetic nurse practitioner, Sharon Bennett

C A S E S T U DY

Gemma Johnson, 31, came to see me because she was

with aesthetic nurse practitioner, Sharon Bennett looking for a natural looking enhancement to her lips. She had well-proportioned lips and a well defined cupid’s

Gemma Johnson, 31, to see me when because she was bow, but felt that hercame lip disappeared she smiled. with with aesthetic aesthetic nurse nurse practitioner, practitioner, Sharon SharonBennett Bennett Gemma Johnson, 31, came to see me because she was looking looking for a natural looking enhancement to her lips. During the consultation I noticed that her philtral columns She had well-proportioned lips and well defined cupid’s for a natural looking enhancement toa her lips. She had wellwere slightly flat and there was also asymmetry between Gemma Gemma Johnson, Johnson, 31, 31,came came to to see seeme mebecause because she sheshe was wassmiled. bow, lip disappeared when proportioned lips her and a well defined cupid’s bow, but that her lip thebut leftfelt andthat right side of the lip which would be felt corrected looking looking for for aanatural natural looking lookingI enhancement enhancement to toher her lips. lips. columns During the consultation noticed that her philtral during the treatment. disappeared when she smiled. During the consultation I noticed that with aesthetic nurse practitioner, Sharon Bennett She Shehad had well-proportioned well-proportioned lips lipsand and aaasymmetry well welldefined defined cupid’s cupid’s were slightly flat andwere there was also between her philtral columns slightly flat and there was also asymmetry I explained howher I would minimize the discomfort with bow, bow, but but felt feltright that that her lip lip disappeared when when she she smiled. the left and side ofdisappeared the lipofwhich would besmiled. corrected between the left31, and right side the lipme which would be corrected a lidocaine gel, which would allow to observe the lip Gemma Johnson, came to see me because she was During During the the consultation consultation I I noticed noticed that that her her philtral philtral columns columns during the treatment. movement (smiling and pouting) through the procedure during the treatment. looking for a natural looking enhancement to her lips. were wereslightly slightly flat flatand and there therewas was also alsoasymmetry asymmetry between between I explained how minimize discomfort with ensure theIside product is lip evenly placed. Bruising is Iand explained how Iwould would the discomfort with a lidocaine She had well-proportioned lips and athe well defined cupid’s the the left left and andright right side of ofminimise the the lipwhich which would would be be corrected corrected a lidocaine gel, which would allowbut me tolip observe the(smiling lip always possible with treatment slow injections, carefuland bow, but felt that her lip disappeared when she smiled. gel, which would allow me to observe the movement during duringthe thetreatment. treatment. movement (smiling and pouting) through the procedure placement and avoiding vigorous massage post treatment, During the consultation I noticed that her philtral columns pouting) through the procedure and ensure the product is evenly Iand Iexplained explained how how IIwould wouldminimize minimize the thediscomfort discomfort with with ensure the product is evenly placed. is along with cool packs can minimize theBruising potential. were slightly flat and there was also asymmetry between placed. Bruising is always possible with treatment but slow injections, aalidocaine lidocaine gel, gel,which which would wouldallow allow me to toobserve observethe the lip lip possible with butme slow injections, careful thealways left and right side oftreatment the lip which would be corrected careful placement and avoiding vigorous massage post treatment, movement movement(smiling (smiling and andpouting) pouting) through the the procedure procedure placement and avoiding vigorousthrough massage post treatment, during the treatment. Restylane ™ is athe beautiful along with coolproduct packsKysse can minimize the potential. and and ensure ensure the the product isisevenly evenly placed. placed. Bruising Bruisingisis along with cool packs can minimize potential.

“ Kysse™ is a beautiful ““Restylane product, it’s so soft and integrates well” “ “

BEFORE

AFTER

The BEFORE perpendicular lip lift AFTER This is a technique I have been using more and more

as it uses a small amount of filler Before After a beautiful The perpendicular lip and liftgives

eversion of the lip. It can also be incorporated with This isperpendicular a techniques. technique I have been using more and more other The lip lift as it is uses a small amount of filler and gives a beautiful This a technique I have been using more and more as it I injected from the vermillion border travelling along eversion of the lip. It can also be incorporated with the red lip towards the wet dry border in a superficial uses a small amount of filler and gives a beautiful eversion BEFORE AFTER This Thisisistechniques. a atechnique techniqueIIhave havebeen beenusing usingmore moreand andmore more other plane, retrograde supportive struts. This gives of it the lip. Itinjecting also be incorporated with other techniques. as as ituses uses aacan small small amount amount of offiller filler and andgives gives aabeautiful beautiful II injected from the vermillion border travelling along an eversion of the lip weight of with injecting injected from the vermillion border travelling along the red eversion eversion of ofthe the lip. lip. ItItcan canwithout also also be bethe incorporated incorporated with thelarger red lip towardswhich the wet dry border ingive a superficial volumes, can sometimes a heaviness lip towards the wet dry border in a superficial plane, injecting other other techniques. techniques. plane, injecting retrograde supportive struts. This gives and thickness to the lip tissue. The additional Thisretrograde is a technique I have been using and more supportive struts. This givesmore an eversion ofbenefit the Ian Iinjected injected from from the thevermillion vermillion border border travelling travelling along along of amount the lip without the weight ofbeautiful injecting iseversion that, if placed correctly, the product will track along as it uses a small of filler and gives a lip without weight of injecting volumes, which can the the red redvolumes, lip lipthe towards towards the the wet wetsometimes dry drylarger border border in inaasuperficial larger which can give asuperficial heaviness the of natural vermillion. eversion the lip. Itheaviness can also be incorporated with sometimes give a and thickness to the lip tissue. plane, plane, injecting injecting retrograde retrograde supportive supportive struts. struts. This This gives gives andtechniques. thickness to the lip tissue. The additional benefit other Injection sites – an an eversion eversion of ofbenefit the the lip lipiswithout without the the weight weight of oftrack injecting injecting The additional that, the if placed correctly, the product is that, if placed correctly, product will along of 0.02ml–0.05ml I injected from the vermillion border travelling along larger larger volumes, volumes, which which can can sometimes sometimesgive giveaRestylane aheaviness heaviness will track along the natural vermillion. Kysse™ the natural vermillion. theand redthickness lip towards the wet dry border in a superficial and thickness to tothe thelip liptissue. tissue. The Theadditional additional benefit benefit Injection sites – plane, injecting retrograde supportive struts. This isisthat, that, ififplaced placed correctly, correctly, the theproduct product will will track trackgives along alongof 0.02ml–0.05ml anthe eversion ofvermillion. the lip without the weight of Restylane injectingKysse™ thenatural natural vermillion. larger volumes, which can sometimes give a heaviness Injection Injectionsites sites–– and thickness to the lip tissue. The additional benefit of 0.02ml–0.05ml 0.02ml–0.05ml of Restylane Restylane Kysse™ Kysse™ is that, if placed correctly, the product will track along the natural vermillion.

The Theperpendicular perpendicularlip liplift lift

I explained how I would minimize the with careful always always possible possible with withso treatment treatment but butdiscomfort slow slow injections, injections, careful product, it’s soft and integrates well.” a lidocaine gel, which would allow me to observe the lip placement placement and and avoiding avoiding vigorous vigorous massage massage post post treatment, treatment, Restylane Kysse ™ is a beautiful movement (smiling and pouting) through procedure SHARON BENNETT along along with with cool cool packs packs can canminimize minimize the thethe potential. potential. andproduct, ensure the product is evenly placed. Bruising is well.” it’s so soft and integrates Lumps are with usually caused but by poor technique always possible treatment slow injection injections, careful Restylane Restylane Kysse Kysse ™™isisproduct. aabeautiful beautiful SHARON BENNETT and/or selecting the wrong Using too much placement and avoiding vigorous massage post treatment, SHARON BENNETT product in one area can cause the potential. product to collect, along with cool canand minimize the product, product, it’s it’spacks so sosoft soft and integrates integrates well.” well.” Lumps are usually caused by poor injection technique protrude and look unsightly. SHARON SHARON BENNETT BENNETT and/or selecting the wrong product. Using too much Modern day fillers are tailored with different properties Restylane Kysse ispoor athe beautiful product in one area can ™ cause product to collect, Lumps are usually caused by injection technique for each indication. Lips are the mobile partand/or of our Lumps Lumpsare are usually usually caused causedby bypoor poormost injection injection technique technique protrude and look unsightly. product, it’s so soft and integrates well.” selecting the wrong product. Using too much product in one area face, and require a low-medium elasticity and cohesivity and/or and/orselecting selectingthe thewrong wrongproduct. product.Using Usingtoo toomuch much Modern day fillers are tailored with different properties can cause the product to collect, protrude and look unsightly. to allow for movement, which iscollect, why I opt SHARON BENNETT product product in inone onethat area areanatural can cancause cause the theproduct product to to collect, forModern each indication. Lips are the most mobile part offor our day fillers are tailored with different properties each for Restylane Kysse™. protrude protrudeand andlook lookunsightly. unsightly. face, andusually require a low-medium elasticity and cohesivity indication. Lips caused are the most mobile part of our face, and require Lumps are by poor injection technique to aallow for that natural movement, which is for why I opt low-medium elasticity cohesivity to allow that natural and/or selecting the wrongand product. Using too much for foreach eachindication. indication. Lips Lipsare arethe themost mostmobile mobilepart partof ofour our for Restylane Kysse™. product in one area can cause the product to collect, movement, which is why I opt for Restylane Kysse™ face, face,and andrequire requireaalow-medium low-mediumelasticity elasticityand andcohesivity cohesivity Injection sites – protrude and look unsightly. 0.02ml–0.05ml of Kysse™ I injected approximately 0.02-0.05ml of Restylane to toallow allow for for that that natural natural movement, movement, which which is is why why I I opt opt • A thorough lip consultation is a must. Make Restylane Kysse™from at approximately 0.5cm intervals. This changes Modern day fillers are tailored with different properties for forRestylane Restylane Kysse™. sure Kysse™. you point out any idiosyncrasies and patient to patient, the size of the lip and what you for eachTop indication. tips Lips are the most mobile part of our take high quality before and after photos I injected approximately 0.02-0.05ml of Restylane Kysse™ want to achieve. 0.02-0.05ml face, and require a low-medium elasticity and cohesivity › A thorough lip consultation is a must. Make sure you point I injected approximately of Restylane Kysse™ at • A thorough lip consultation is a must. Make Spend time looking at the natural shape of the at approximately 0.5cm intervals. This changes from to allow•for that natural movement, which is why I opt I did not place the product in changes the corners Gemma’s out you any idiosyncrasies take high quality approximately 0.5cm intervals. This fromof patient to sure point out anyand idiosyncrasies andbefore and lips and how they fit with the rest of the face patient to patient, the size of the lip and what you for Restylane lips and started the injections 1 cm from the corner take high quality before and after photos afterKysse™. photos patient, the size of the lip and what you want to achieve. Iwant Iinjected injected approximately approximately0.02-0.05ml 0.02-0.05mlof ofRestylane RestylaneKysse™ Kysse™ to achieve. Consider lip the cupid’s bow,isisthe shape of the lips, •• •›A ASpend thorough thorough lipconsultation consultation aashape must. must. Make Make of the upper lip.0.5cm time looking looking atatthe natural of the at atapproximately approximately 0.5cmintervals. intervals.This Thischanges changesfrom from • Spend time the natural shape of lips theand how compare theout topany andidiosyncrasies bottom lip, look inside I did not place the product in the corners of Gemma’s sure sure you youpoint point out any idiosyncrasies and and If anot patient requires asize fuller lip then I of use Restylane™ they fit with restfit ofwith the face Ipatient did place the product inof the corners Gemma’s patient to to patient, patient, the thesize ofthe the lip lipand and what what you you lips and howthe they the rest of the face the lip and seebefore if thereand areafter any abnormalities lips and started the injections 1 cm from the corner take take high high quality quality before and after photos photos inand combination with this technique andcorner cross of hatching want want to to achieve. achieve. › Consider the cupid’s bow, the shape of the lips, compare lips started the injections 1 cm from the the • Consider the cupid’s bow, the shape of the lips, of the upper lip. Don’t justlooking look at at the front of the face of with an •• • Spend Spend time time looking atlook the the natural natural shape shape ofsee the the I injected approximately 0.02-0.05ml ofbolus Restylane Kysse™ using linear threads and/or small injections. the top and bottom lip, inside the lip and if there upper lip. I I did did not not place place the the product product in in the the corners corners of of Gemma’s Gemma’s compare lip theconsultation top and bottom lip, look inside • A thorough is a must. Make anterior posterior approach. Look at oblique If a patient requires a fuller lip then use Restylane™ lips lips and andhow how they theyfit fitwith withthe therest rest of ofthe thean face face at approximately 0.5cm intervals. ThisI changes from injections11cm cmfrom fromthe thecorner corner lips lipsand andstarted startedthe theinjections are any abnormalities the lip and see ifany there are any abnormalities sure you point out idiosyncrasies and view and measure angles toshape createof balance in combination this of technique andwhat crossyou hatching patient to patient, with the size the lip and •• take Consider Consider the the cupid’s cupid’s bow, bow, the the shape of the the lips, lips, of ofathe the upper upper lip. lip. a fuller lip then I use Restylane™ in Don’t just look before at ofafter the face with with an anterior Ifusing patient requires highjust quality and photos • › Don’t look atthe thefront front of the face an linear threads and/or small bolus injections. want to achieve. • compare Look at the face in bottom animation, pouting, compare the the top top and and bottom lip, lip,smiling, look look inside inside posterior approach. Look at an oblique view and measure combination with this technique and cross hatching using If If a a patient patient requires requires aafuller fullerlip lip then then IIuse use Restylane™ Restylane™ anterior posterior approach. Look at an • Spend time looking at the natural shape of oblique the rest the theat lip lip and andsee seeififthere thereare areany anyabnormalities abnormalities I did not place the product in the corners of Gemma’s in in combination combination with with this this technique technique and and cross cross hatching hatching angles to create balance linear threads and/or small bolus injections. view and measure angles to create balance lips and how they fit with the rest of the face lips and started the injections 1 cm from the corner Galderma’s Harmony Programme has a series •• •›Don’t Don’t just just look look at atthe the front front of of the theface face with with an an using using linear linear threads threadsand/or and/or small smallbolus bolusinjections. injections. Look Look at the face animation, smiling, at rest at the faceininbow, animation, smiling, pouting, Sharon Bennett RGN, NIP, • • Consider the cupid’s the ofpouting, the lips, of the upper lip. of questions to approach. make sureshape that the consultation anterior anterior posterior posterior approach. Look Look at at an an oblique oblique › Galderma’s Harmony Programme has a series of questions at rest the top and bottom lip, look inside compare PG Dip Cosmetic Intervention is as thorough as possible and unrealistic view view and and measure measure angles angles to tocreate create balance balance If a patient requires a fuller lip then I use Restylane™ to make sure theare consultation is as thorough lip and see ifthat there any abnormalities is a founder and current chair of the • theGalderma’s Harmony Programme has a seriesas expectations are flagged Sharon Bennett RGN, NIP, Dip hatching Cosmetic in Sharon combination with RGN, this technique andPG cross •• Look Lookat atthe the face face in inanimation, animation, smiling, smiling, pouting, pouting, BritishBennett Association ofaNIP, Cosmetic Nurses (BACN). and unrealistic expectations flagged ofpossible questions to make sure that the are consultation • Don’t just look at the front of the face with an Intervention is founder and current chair of the using linear threads and/or small bolus injections. • at Make sure you know the anatomy of the lip at rest rest PGShe Dipis Cosmetic director ofIntervention the award-winning clinic,(BACN). Harrogate › isMake sure you as know the anatomy of an theoblique lip as thorough possible and unrealistic British Association of Cosmetic Nurses She anterior posterior approach. Look at •›Galderma’s The superior and inferior labial arteries usually is aAesthetics founder and chairofofthe theGalderma andcurrent a of member Faculty. •• view Galderma’s Harmony Harmony Programme Programme has has aaseries series is director the award-winning clinic, Harrogate expectations The and inferior labial arteries usually run below are flagged andsuperior measure angles to create balance Sharon Sharon Bennett Bennett RGN, RGN, NIP, NIP, British Association Cosmetic (BACN). run belowto 4.5mm are different in the upper Aestheticsof and a memberNurses of the Galderma Faculty. of of4.5mm questions questions tomake makeand sure sure that that the theconsultation consultation and are different the upper and lower Make sure you theinanatomy of the lip lip. When • • Look at the face inknow animation, smiling, pouting, PG PGDip Dip Cosmeticof Intervention Intervention She is Cosmetic director the award-winning clinic, Harrogate and lower lip. using a unrealistic needle the safest isisas as thorough thorough as asWhen possible possible and and unrealistic using a needle theinferior safest plane will be no deeper than 4mm rest isAesthetics isaafounder founderand and andacurrent current chair chair of ofthe the • at expectations The superior and member of the Galderma Faculty. plane will be no deeperlabial than arteries 4mm usually expectations are are flagged flagged British BritishAssociation Associationof ofCosmetic CosmeticNurses Nurses(BACN). (BACN). run below 4.5mm and are different the upper • Galderma’s Harmony Programme has ainseries lip •• Make Makesure sureyou youknow knowthe theanatomy anatomyof ofthe thelip Sharon RGN, NIP, She SheisisBennett director directorof ofthe theaward-winning award-winningclinic, clinic,Harrogate Harrogate and lower to lip.make When using a the needle the safest of questions sure that consultation •RESXXX • is as The The superior superior and and inferior inferior labial labial arteries arteries usually usually PG Dip Cosmetic Intervention Aesthetics Aesthetics and and a a member member of of the the Galderma Galderma Faculty. Faculty. DOP April 2019 plane will be no deeper than 4mm thorough as possible and unrealistic is a founder and current chair of the expectations are flagged British Association of Cosmetic Nurses (BACN). and andlower lowerlip. lip.When Whenusing usingaaneedle needlethe thesafest safest •RESXXX Make sure you know the anatomy of the lip She is director DOP April 2019 60 Aesthetics | January 2020 of the award-winning clinic, Harrogate plane plane will will be beno nodeeper deeperthan than4mm 4mm • The superior and inferior labial arteries usually Aesthetics and a member of the Galderma Faculty.

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A summary of the latest clinical studies Title: Fractional C02 Laser Plus Topical Antifungal Versus Fractional CO2 Laser versus Topical Antifungal in the Treatment of Onychomycosis Authors: Zaki A, Abdo H, Ebadah M. Published: Dermatologic Therapy, December 2019 Keywords: Onychomycosis, Tioconazole, Laser Abstract: Onychomycosis is an important medical disorder affecting both health and quality of life of patients. This study was done to compare the efficacy of CO2 laser in combination with topical tioconazole versus CO2 laser only versus topical tioconazole alone in onychomycosis. A total of 120 patients with onychomycosis were randomly assigned to three groups. Group A patients were treated with fractional CO2 laser followed by topical tioconazole 28% for five sessions with 3 weeks interval. Group B patients were treated with fractional CO2 laser for five sessions with 3 weeks interval. Group C patients were treated with only topical tioconazole 28% for 16 weeks. The clinical effect, KOH examination, and culture for the affected nails in the three groups were analysed. One month after the last session, regarding clinical response, 55% showed complete clinical improvement in Group A versus 30% in Group B versus 25% in Group C with a significant difference in between. There was a significant difference between the three studied groups as regard KOH test and culture after treatment. Fractional CO2 laser combined with topical antifungal is a safe and effective treatment for onychomycosis. Title: Doppler Ultrasound-Guided Thread Lifting Authors: Lee W et al. Published: Journal of Cosmetic Dermatology, December 2019 Keywords: PDO threads, Ultrasound, Complication prevention Abstract: Although there are various techniques of thread lifting, most of these techniques require anchoring of the threads at the temple area. However, the frontal branch of the superficial temporal artery (FBrSTA) is located in the temple area and a detour pathway should be created for thread insertion to avoid vascular complications. We aimed to determine the relationship between the FBrSTA and the hairline using realtime Doppler ultrasound. Doppler ultrasound was used to detect the FBrSTA pathway, and the relationship between the hairline and the FBrSTA was analyzed. After confirming the arterial pathway, thread lifting was performed in patients, and complications related to the entry point and insertion of the threads were evaluated. Patient satisfaction was evaluated immediately after the procedure and 3 months later. This study included 50 patients (45 women and 5 men; age: 51 [range 26-71] years) who underwent thread lifting in a single institution from January to May 2019 after Doppler ultrasound-guided detection of the FBrSTA. No vascular complications were noted in all patients. Our findings suggest that Doppler ultrasound can be used to detect the FBrSTA at the temple area to avoid vascular complications during thread lifting.

Title: Adipose-derived Stromal/Stem Cells Improve Epidermal Homeostasis Authors: Moriyama M et al. Published: Scientific Reports, December 2019 Keywords: Stem cells, Wound healing, Skincare Abstract: Wound healing is regulated by complex interactions between the keratinocytes and other cell types including fibroblasts. Recently, adipose-derived mesenchymal stromal/stem cells (ASCs) have been reported to influence wound healing positively via paracrine involvement. However, their roles in keratinocytes are still obscure. Therefore, investigation of the precise effects of ASCs on keratinocytes in an in vitro culture system is required. Our recent data indicate that the epidermal equivalents became thicker on a collagen vitrigel membrane co-cultured with human ASCs (hASCs). Co-culturing the human primary epidermal keratinocytes (HPEK) with hASCs on a collagen vitrigel membrane enhanced their abilities for cell proliferation and adhesion to the membrane but suppressed their differentiation suggesting that hASCs could maintain the undifferentiated status of HPEK. Contrarily, the effects of co-culture using polyethylene terephthalate or polycarbonate membranes for HPEK were completely opposite. These differences may depend on the protein permeability and/or structure of the membrane. Taken together, our data demonstrate that hASCs could be used as a substitute for fibroblasts in skin wound repair, aesthetic medicine, or tissue engineering. It is also important to note that a co-culture system using the collagen vitrigel membrane allows better understanding of the interactions between the keratinocytes and ASCs. Title: The Structure and Classification of Botulinum Toxins Authors: Dong M and Stenmark P Published: Handbook of Experimental Pharmacology, December 2019 Keywords: BONT, Rejuvenation Abstract: Botulinum neurotoxins (BoNTs) are a family of bacterial protein toxins produced by various Clostridium species. They are traditionally classified into seven major serotypes (BoNT/A-G). Recent progress in sequencing microbial genomes has led to an ever-growing number of subtypes, chimeric toxins, BoNT-like toxins, and remotely related BoNT homologs, constituting an expanding BoNT superfamily. Recent structural studies of BoNTs, BoNT progenitor toxin complexes, tetanus neurotoxin (TeNT), toxin-receptor complexes, and toxin-substrate complexes have provided mechanistic understandings of toxin functions and the molecular basis for their variations. The growing BoNT superfamily of toxins present a natural repertoire that can be explored to develop novel therapeutic toxins, and the structural understanding of their variations provides a knowledge basis for engineering toxins to improve therapeutic efficacy and expand their clinical applications.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Understanding Tax Requirements Accountant Samantha Senior details what new practitioners need to know about becoming selfemployed and registering for tax Tax season is here. The self-assessment tax return deadline for the last tax year is January 31; the end of this month. This means it’s perfect timing to discuss the responsibilities of a sole trader in regards to personal income tax when starting out in the medical aesthetics specialty. I am regularly approached by medical professionals who have invested in themselves through training as aesthetic practitioners. They often move from employed roles in the NHS and are taking the leap to become self-employed, which can be daunting for many. As life and work are busy, the formality of registering the new business gets pushed down the to-do list and often becomes a cause of anxiety and panic later down the line. The most common questions I get asked in my tax clinics are: • “How do I register my business?” Or “Help! I haven’t registered my business; will I get in trouble?” • Followed by, “Does THIS tax deadline affect me?” • “How much tax do I need to pay?” • And “What is making tax digital?” As an accountant, I meet many business owners that get completely overwhelmed by the concept of small business accounting and tax, so this article aims to help simplify the basic steps and advise those new to

the industry on what responsibilities lay with becoming a sole trader, while providing practical advice on when they should submit a self-assessment tax return.

Registering as a business Taking the leap from leaving employment and becoming self-employed needn’t be scary. A few simple steps and you’re ready to go. When starting out, the first step is to decide what type of business you want to be. In the UK, the simplest way to set up a business is to become a sole trader, also referred to as ‘self-employed’. The alternative is to set up as a limited company. Setting up as a limited company may be of benefit later down the line when your business grows, as it can be more tax efficient, but there is a lot more administration and responsibility with being a limited

company than a sole trader. As such, I generally recommend that becoming a sole trader is the easiest and most common route for newly-trained practitioners. There are a lot of free resources online, either at HMRC or the Low Income Tax Reform Group (LITRG), which is a charity that offer a free 108-page document on self-employment; as well as unlimited free resources.1 They both offer a wealth of advice on the advantages and disadvantages of being a limited company or a sole trader if you want to know more, or you can read Sole Traders vs. Limited Companies by Dr Qian Xu, which was published in the June 2018 issue of Aesthetics and is available online.2 For this article, however, I will focus on the responsibilities of sole traders. HMRC states that as a sole trader it is your responsibility to: • Keep records of your income and expenditure • Send a self-assessment tax return every year to HMRC • Pay income tax on your profits and Class 2 and Class 4 national insurance, if profits exceed the respective thresholds3 When you decide to become self-employed you are responsible for your own personal tax and national insurance. For these to be accounted for, you must register as self-employed. According to HMRC, ‘You must have done so by October 5 in your business’s second year and you could be fined if you are not’.3 A tax year runs from April 6 to April 5, therefore if you start your business in February 2019 you will have until the October 5, 2019 to register. If you start your business in June 2019, you have until the October 5 2020 to register. It’s simple to register as a sole trader; it just involves filling out a form on the gov.uk website.3 It can be completed by the individual running the business or by an accountant on behalf of the business owner.

Taking the leap from leaving employment and becoming selfemployed needn’t be scary

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Accounting records and Making Tax Digital Developing a good accounting system early on in business is the best foot forward. I encourage new businesses to ensure they have a separate business bank account as soon as they start trading. The next advice I would give is to start organising a bookkeeping system that works for the business owner, which is simple and non-complicated. Making Tax Digital is here to stay. According to HMRC, the primary aim is to make tax administration more effective, efficient, and easier for taxpayers through the implementation of a fully digitalised tax system.4 In April 2019, HMRC made it mandatory for all VAT registered (over the VAT Threshold) businesses to become digital – meaning all VAT Returns to be submitted using a digital accounting system. With income tax becoming mandatory by 2021 (earliest),3 I would advise that new businesses find a digital book-keeping system that they are comfortable using and understanding. There is a vast amount of accountancy software products on the market that are user-friendly and have apps that will work on most smartphones. I recommend using one that will grow with your business and is compliant with HMRC. You should look out for software that has: • Recording ability – can record and keep a digital image of a receipt • A payroll system – if/when you take on staff having a system that already includes a payroll feature would be prudent • Permission setting – does it have permission levels for staff to use? For example, you may want staff members’ input and the ability to record their own expenses or their invoices/sales for clients, but not see all your financial information for the business • A stock feature – as you grow, keeping clear and accurate records of your stock levels is imperative for stock control • Ability to submit VAT Returns if you become VAT Registered Most accountancy software companies offer free training and webinars to get the best out of their products and apps. Sage, QuickBooks, Xero and FreeAgent are the products I have found very practical for businesses. Their basic standard packages generally range from £10 to £30 per month. For my clients working in aesthetics I have found FreeAgent is taking the lead, with users having no previous accountancy or

Start organising a book-keeping system that works for the business owner which is simple book-keeping knowledge and finding it easy to use. In my experience, its functionality fits around the modern business; everything can be completed easily on a smartphone, allowing business owners to successfully juggle their life/work balance. There are no additional apps to be purchased to photograph receipts. FreeAgent can also be obtained free when banking with NatWest and is free for all NatWest business account holders. NatWest also offers free business banking for new businesses for 18 months.5

Business and training expenses As stated on the HMRC’s website; ‘If you’re self-employed, your business will have various running costs. You can deduct some of these costs to work out your taxable profit as long as they’re allowable expenses. Costs that relate to your business and certain training expenses can be claimed against your business turnover/income as ‘allowable expenses’. For example, if your turnover is £40,000, and you claim £10,000 in allowable expenses, you only pay tax on the remaining £30,000 – known as your taxable profit.3 According to HMRC, costs you can claim as allowable business expenses include:3 • Office costs e.g. stationery or phone bills • Travel costs e.g. fuel, parking, train or bus fares • Clothing expenses e.g. uniforms • Staff costs e.g. salaries • Things you buy to sell on e.g. stock or raw materials • Financial costs e.g. insurance or bank charges • Costs of your business premises e.g. heating, lighting, business rates • Advertising or marketing e.g. website cost As most aesthetic practitioners invest in themselves by committing to expensive training courses, it is likely these are directly relevant to your business and are used to keep your current skills updated. This therefore means that the costs for these can be claimed against your income, lowering

your tax liability. HMRC states, ‘You can claim allowable business expenses for training that helps you improve the skills and knowledge you use in your business (for example, refresher courses)’. As such, I recommend keeping all your receipts for training and have an accountant double check what training courses are allowable. All allowable training courses enable you to claim further expenses in relation to the allowable training course; for example, travel costs, and expenses relating to the materials needed for the course. If you are in doubt, please speak to an accountant. You cannot claim for training courses that help you:3 • Start a new business • Expand into new areas of business, including anything related to your current business For example, if you were a self-employed dentist and you trained to give botulinum toxin injections, this would NOT be claimable. Yet, if you were a self-employed toxin injector already, and you committed to a CPD course to refresh your skills, then this WOULD be claimable.

Tax return Once you have your expenses and income recorded for the tax year, you will need to complete an annual self-assessment tax return. Self-assessment is to calculate your personal tax liability including income tax, Class 2 and 4 national insurance (NI) and capital gains tax for the tax year. • Income Tax for the 2019/20 tax year is calculated on profits after the £12,500 personal tax allowance has been disregarded. Any profits remaining after deducting the personal allowance will be taxed at 20% from £0 to £37,500, 40% from £37,501 to £137,500, then any after will be taxed at 45%. If your total income exceeds £100,000 your personal allowance is tapered down by £1 for every £2 until £125,000, when you will no longer receive a personal allowance.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


• Class 2 NI at £3 per week for the 2019/20 tax year. You only need to pay Class 2 NI if your annual profits are above £6,365. However, you can make voluntary contributions to maintain your national insurance record.

DISTINGUISHED BY ITS SHEER VERSATILITY

• Class 4 NI at 9% on profits between £8,632 and £50,000, reducing to 2% on profits over £50,000 for the 2019/20 tax year. The deadline to complete your tax return is January 31 every year unless you prepare a paper return which is due by October 31 following the end of the tax year. Therefore, for the tax year that ended April 5 2019, if you are completing your tax return online, you will need to submit and pay all tax by January 31, 2020. It is common for most businesses to make a loss in the first years of trading. A trading loss occurs when the business outgoings are more than the business income. For example, if a business made £40,000 in income but paid out £50,000 to make that income, the business would have a loss of £10,000. This loss can be recorded on your tax return. If you are employed and have paid tax during the tax year, this loss can be allocated against the tax paid on your employment income, potentially resulting in a tax refund. Alternatively, if you have made a loss and are not employed or have not paid tax in the tax year, the loss can be carried forward into the following next three tax years to be netted off against any future profits, potentially resulting in reducing your future tax liabilities.1 For further reading on tax losses I would recommend reading the free resources at HMRC or LITRG.

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Summary My recommendations for self-employed aesthetics practitioners who are new to the industry are to firstly begin with registering for self-assessment as soon as possible and open a separate business bank account. You should always keep records of all business income and expenditure and find a user friendly (HMRC compliant) accounting software/app to assist you. Understanding and managing tax doesn’t need to be difficult, there are plenty of free resources available that can help you and everything is becoming much similar with the new Making Tax Digital processes. Samantha Senior is the founder of SAS Accounting, which was established in 2004. She is a member of the Association of Accounting Technicians and has experience in accounting for small and medium businesses, as well as large limited companies. SAS has a division focusing on the personal tax for sole traders working in aesthetics. REFERENCES 1. Low Incomes Tax Reform Group, Self-employment (UK: LITRG, 2019) <https://www.litrg.org.uk/ tax-guides/self-employment> 2. Dr Qian Xu, Sole Traders vs. Limited Companies (UK: Aesthetics, 2018) <https://aestheticsjournal.com/feature/sole-traders-vs-limited-companies> 3. Gov.uk, Register for and file your self-assessment tax return (UK: Gov, 2019) <https://www.gov. uk/log-in-file-self-assessment-tax-return/register-if-youre-self-employed> 4. Thomson Reuters, What is Making Tax Digital? (UK: Thomson Reuters, 2019) <https://tax.thomsonreuters.co.uk/making-tax-digital/what-is-making-tax-digital/> 5. Natwest, Personal Banking (UK, Natwest, 2019) <https://www.business.natwest.com/ business/businessbanking/services/freeagent.html?extcam=N_PPC_Google_Bus_FreeAg_66513103111_319526196718_natwest%20freeagent&gclid=Cj0KCQiAz53vBRCpARIsAPPsz8WSN0YPqgh9HaWsJZFAMFG7H7exkDvDA_TmZZDqFb_iqOM9sz0-N5AaAsiqEALw_ wcB&gclsrc=aw.ds> 6. Gov.uk, Income tax rates and allowances for current and past years (UK: Gov, 2019) <https:// www.gov.uk/government/publications/rates-and-allowances-income-tax/income-tax-rates-andallowances-current-and-past> 7. LITRG, What if I make a loss? <https://www.litrg.org.uk/tax-guides/self-employment/working-out-profits-losses-and-capital-allowance/what-if-i-make-loss>

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05.12.2019 16:36:21


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day and time of the week are most people available? A weekend may work well for you, but your patients may not want to give up time with their family. We have run microevents in the clinic itself for four and a half years now, so we’ve pretty much tested every month of the year, day and time! Because of this, we knew that a mid-week afternoon and evening session in November would work well. When choosing the venue, we knew we needed something close to the clinic that was easy enough to get to. I also had a vision that it should be very classic and timeless, which I knew my patients would relate well to. Hedsor House is quintessentially British – it is magnificent and magical! It was fantastic to fuse the history and legacy of the building with the state-ofthe-art technology and evolution of medical aesthetics that we were showcasing.

Running Patient Educational Events Miss Sherina Balaratnam discusses key considerations when hosting events for your patients On November 20, surgeon and aesthetic practitioner Miss Sherina Balaratnam hosted an exclusive winter event for patients and interested guests at Hedsor House; a beautiful manor house situated near her clinic, S-Thetics, in Buckinghamshire. Beyond the Facelift was designed to educate Miss Balaratnam’s patient demographic on the ageing process and treatments available at S-Thetics. As well as inviting guest speakers to discuss the science and evolution of medical aesthetics, the clinician hosted her key partner suppliers to showcase the equipment and products on offer at her practice. Attendees were able to have complementary skin consultations, try out products and treatments, and took home a goody bag of products, worth more than £100. Aesthetics attended the event and spoke to Miss Balaratnam about the benefits and challenges of running one…

events such as this allows them to learn more about the ageing process, the types of treatments on offer, how they work and, importantly, who would be treating them.

Again, you need to think about what your patients have shown interest in throughout the year and tie this with current industry trends. I really advocate introducing voices other than your own, so patients can hear from experts in various fields. This particular agenda came very easily to me. After running patient educational events for so long, I understand what my demographic is interested in and what they’d like to learn more about. I knew I wanted to

Agenda Why should practitioners host these events? Like other medical professionals, I’ve had the fortune of being educated my whole life and appreciate that to move forward in anything, we need to continue to learn. We are lucky to be educated to an elite level in medical aesthetics, always discovering new products and how they work. I leave industry educational events feeling so inspired, that I want to take what I have learnt to our end users, our patients. I also want to educate and inspire my team – the more they know and the more they learn, the better they become at what they do. This ultimately delivers higher patient satisfaction, which is of course very rewarding.

What is a patient educational event? For me, it is an opportunity for a new or existing patient to really get an insight into what aesthetics is about. Some audience members may be new to the area or never have had aesthetic treatment before. Hosting

Tell us about how to create an agenda...

How can practitioners decide on the location and date for events? Think about what will work well for your patients – where can they reach easily through various modes of transport? What

Two sessions took place – one from 12-4pm featuring founder of The Tweakments Guide, Alice Hart-Davis and the other from 5-9pm with Tatler’s Health & Beauty Editor at Large, Francesca White. Guest were able to mingle with suppliers, try out treatments and have mini consultations to begin, before the main talks took place, consisting of: • Welcome from Miss Balaratnam • Keynote presentation on skin health, epigenetics, science of ageing and how we treat these from Dr Charlene DeHaven, global clinical director of iS Clinical skincare • Unique insights into the latest global aesthetics and wellness trends from leading beauty journalists Alice Hart-Davis and Francesca White

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Speakers said…

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Key partner suppliers

“I was delighted to be asked to give a talk about Trends in Tweakments at the ‘Beyond the Facelift’ event. Sherina’s invited audience was very engaged; they knew a good deal about medical aesthetics and asked a great many pertinent questions!” Alice Hart-Davis, founder of theTweakmentsGuide.com “It was a real privilege to be asked to speak about ‘The New Face of Health’ at Miss Sherina Balaratnam’s Hedsor House event. Not only was there great engagement across the evening, but it was brilliant to be able to speak direct to consumers – something that we need more of in the industry (and which Sherina is as passionate about steering as I am!).” Francesca White, Tatler’s Health & Beauty Editor-at-Large

Suppliers said… “We were delighted to be invited to support your one of a kind event at beautiful Hedsor House which featured a unique opportunity for patients and consumers, curious to learn more about the very latest in advanced medical aesthetics, with keynote presentations from world-renowned speakers, on skin health, epigenetics and the science of skin and facial ageing.” Anita Eyles, Totally Derma “As leaders in aesthetics, we have the responsibility to educate, engage and empower consumers through experiential activities, media and medical practitioners as part of our Beauty Decoded campaign. Miss Balaratnam, one of our AMI faculty joined us on this journey from the start and recently at this event where she elegantly supported her consumers demystify the misconceptions around facial fillers and showing them the potential of achieving natural looking. She guided them though a holistic journey backed up a variety of scientificallyproven modalities, that could be individually customised to their needs.” Nancy Ghattas, UK Country Manager, Allergan

• • • •

AesthetiCare – Endymed Allergan – Beauty Decoded BTL Aesthetics – EMSculpt Cynosure – Icon, PicoSure and SculpSure

• • • • •

Hydrafacial iS Clinical Oxygenetix foundation Totally Derma nutraceuticals VISIA digital skin imaging

select ambassadors from across our profession to speak; offering an international perspective and a fresh approach. It was also important to involve our key partner suppliers in the event – I wanted to bring a sort-of exhibition to the patient. We included every treatment, technology and topical product that we offer at the clinic. Our suppliers have supported us throughout the clinic’s journey, so it was exciting to work on a bigger project with them and take patient education to the next level.

How can clinic owners best market their events? I recommend running both internal and external marketing campaigns to reach both existing and new patients. Internally, you can print invites to give out to all patients and brief staff to be very proactive in talking to everyone about your events. For external communication, I would suggest sending a weekly email newsletter to your database, discussing the event and encouraging them to visit your website for more information. We have a really dynamic website whereby I write regular blog posts about our events, our speakers and what people can learn from attending. We also have a very active social media campaign in place, where we post about the event every day, so would really encourage others to use their social platforms. I interview our speakers and exhibitors, as well as existing patients, so our following can get a real insight into what to expect from the event and from treatments in general. It can be difficult to make time for social media amongst your busy schedule, but I would say the more you do it, the better and faster you become – it does get easier with time!

What advice would you give to practitioners considering running patient educational events? Take baby steps. There’s no way we could have run Beyond the Facelift in year one. It is an investment not just in the monetary sense, but also in space and time. You want to fill the space with things that are going to be well received by your audience, so you have to think practically about what you’re going to do, who can attend and how you can achieve your goals. I think it’s also valuable to have other voices from the profession and the media involved. Having Dr Charlene DeHaven speak so eloquently about the ageing of the skin and considerations for skincare was very special. In addition, Alice Hart-Davis was able to articulate the changes in aesthetics and her wealth of experience in having treatments over the last 20 year excellently, while Francesca White offered really wonderful insight into how we can incorporate wellness into aesthetics and bring better quality results to our patients.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Generating Patient Loyalty Dr Qian Xu explores the importance of patient loyalty and details how she believes this is best gained in a business As competition becomes fiercer in this growing specialty, the cost of acquiring new patients has risen dramatically. Since it is much cheaper to get existing patients to come back to you, it makes a lot of sense to set up patient retention schemes to try to keep your existing patients. Many clinics have such patient retention schemes, but they often involve special deals and offers for existing patients. They find themselves stuck in a price war, fearing that if they raise their prices, their patients will go elsewhere. When you are in such a price war, your business may survive for many years, but it will not thrive. It will be hard work and seem like a constant struggle, and I’m sure that it is not the reason you went into business in the first place. In my experience, there are three ways to beat your competition: be cheaper, better or different. If you don’t want to be cheaper, then you have to be better than or different to your competitors. When you are either of these, price then becomes irrelevant. I have found that this is the foundation to building customer loyalty and the secret to raising your prices to charge what you are really worth. I have built a stable referral-based business that doesn’t rely on paid advertising. Through this process, I have also gained a lot of insight into what made my patients trust me, what made them want to buy from me and what made them stay loyal to me. While traditional loyalty schemes can help bring in repeat business, without true patient loyalty, your business could suffer in the long run.

What is loyalty? Before we can start building customer loyalty, we need to first define what it actually means. According to the Oxford Dictionary, ‘loyal’ means ‘a strong feeling of support or allegiance’.1 This means a loyal patient will come to you when they need a treatment, not just when the price is right. They would make time to see you even if it is inconvenient for them. If they can’t afford your treatments, they will save up until they can afford it, rather than going to someone cheaper. During the tough times in your business, it is your loyal patients that you can count on to help you through. You can’t buy this loyalty; you must earn it.

Many clinics confuse repeat customers with loyal customers. Although repeat customers can also be loyal, they are not necessarily the same thing. How many of your ‘loyal patients’ only come in when you are running an offer? Those people are loyal to the price, not to you. The problem with running offers is that it only solves a short-term problem and it also can become addictive, as this may be when you see a significant uplift in figures. Another issue that you must consider is the Advertising Standards Agency Guidelines, which state, ‘Marketers should ensure that promotions do not encourage consumers to undergo unnecessary or unwanted interventions. Particular care should be taken when offering discounts for packages for procedures or promotional mechanics such as loyalty schemes or incentives for, for example, referring a friend’.2 Putting everything into consideration, I believe that for ultimate success, it is important to not get stuck in this cycle of offers and discounts.

What makes patients loyal? When I think of customer or patient loyalty, the technology company Apple pops into my mind. It seems like people will buy whatever they come out with, and they will buy everything. People are loyal to Apple, but why is this? In author Simon Sinek’s book, Start with Why, he talks about the golden circle with ‘Why’ in the centre, ‘How’ in the next ring, and ‘What’ in the outer ring, like a target, shown in Figure 1.3 Most businesses talk about what they do, and sometimes about how they do it, but very rarely do they talk about why they do what they do. For the aesthetics specialty specifically, everyone can talk about what treatments they do and

In my experience, there are three ways to beat your competition: be cheaper, better or different

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Continuing loyalty The Golden Circle WHY Outline what you are tying to achieve in aesthetics

HOW WHY HOW WHAT

Define your approach. How are you going to do this?

WHAT The specific treatments you offer

Figure 1: The golden circle as described by author Simon Sinek

attempt to explain how they are better than the other practitioners. Maybe they have a Master’s degree, perhaps they use a particular technique, or they have become specialised in one thing, such as lip augmentation. However, almost no one talks about why they do what they do. Other than ‘I want to work less and make more money’, do you have another more meaningful reason for wanting to do aesthetics? Here is what I say when I meet someone new, “I believe that aesthetics is not about keeping up with the Kardashians; it is about maintaining and creating the best version of yourself. This is why I take a holistic and long-term approach and create bespoke treatment plans for each of my patients.” This way of communication has revolutionised my business, and I have been able to convert sceptics into paying patients. These people book a consultation with me without even knowing what treatments I offer, and they often will have whatever treatments I recommend. In my experience, if you can convert sceptics into paying customers, they will often become your most loyal patients.

Results, reliability and responsibility Once you have convinced people to give you a try, these three R’s will help you build and maintain loyalty. Results It is obvious that when people pay you for a set of treatments, they expect certain results. Depending on what treatments you offer, some will give better results than others. I think the saying that you need to under-promise and over-deliver is very appropriate in aesthetics. If someone is

aware that the results may only be very subtle, but are still willing to give it a go, they will less likely be disappointed and are actually likely to be pleasantly surprised. This will be the first step towards building trust and loyalty. Reliability It’s obvious that you should always do what you say you will do, but you should go a step beyond that and do the things that you didn’t say you would do. Things like remembering patients’ birthdays and certain life events, perhaps you can send out little gifts now and again to loyal customers; this would really help to strengthen the loyalty. Responsibility Most people know that there are risks involved in aesthetic procedures. They have seen enough horror stories in the media, which is why many of them are scared. However, what makes most people feel safe is not necessarily how well trained you are (it’s difficult for them to tell), it is what you will do to prevent problems from happening and whether you will be willing to sort out any problems should they arise. I give out my personal mobile number to my patients because if they have any problems, I would want to be the first person they contact. Of course, you can choose to have a separate business phone, so it doesn’t mix with your personal life. A lot of people are worried that they would be inundated with messages if they gave out their number, but when you make it clear to people that you are contactable, they feel safer, and they often won’t contact you with minor things. Even if they get a complication or a result that they didn’t like, as long as you are there for them to sort it out, they are likely to still come back to you for other treatments. Once they trust you, they will not easily go to another practitioner. They will remain loyal to you.

Loyalty cannot be built overnight. After making a good first impression, you need to keep up the good work. The way I think of loyalty schemes is that they are simply systems that you put in place to continuously show your patients that you care about them. When you only have a few patients, you can do this manually. It’s easy enough to drop them a message every few months to see how they are doing and sending them a Happy Birthday message or a Christmas card. When you have more patients, you can automate some of these factors or even delegate them to a virtual assistant. You just need to keep in touch with your patients to remind them that you are here for them should they need anything.

Getting it right Just like love, loyalty comes from the heart, and people can’t always explain why. To win the hearts of your patients, you have to show them that you care, and it helps if you really do care. At the end of the day, I find that it doesn’t always matter what you do for your patient retention strategy, it is the intention behind it that counts. People will forget what you say, but they will never forget how you make them feel. The ultimate aim of any patient retention strategy should be to make your patients feel special, so that they will always choose to come to you and no one else. Dr Qian Xu is the founder and medical director of Skin Aesthetics. She has a background in surgery and emergency medicine and specialised in aesthetic medicine in 2012. Dr Xu was a lead trainer and mentor at Harley Academy in 2017. She has since built up The Aesthetics Practitioners Community on Facebook and also Aesthetics 360 Business Academy to help ethical practitioners succeed. REFERENCES 1. Lexico.com, loyalty <https://www.lexico.com/en/definition/ loyalty> 2. ASA.org.uk, Guidance on the marketing of surgical and nonsurgical cosmetic procedures, January 2016 <https://www.asa. org.uk/resource/cosmetic-interventions.html> 3. Simonsinek.com, Start with why <https://simonsinek.com/ product/start-with-why/>

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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“You’ve got to be able to look after yourself before you look after anyone else” Aesthetic practitioner Miss Mayoni Gooneratne reflects on her career in aesthetics and shares why wellness is a fundamental part of her practice Born in Sri Lanka, Dr Mayoni Gooneratne moved to the UK at the age of three. By the age of nine, her doctor-parents knew that she was going to follow in their footsteps thanks to her passion for caring for others. Miss Gooneratne shares, “In every stage of my life I have always wanted to help and care for others.” She graduated from St George’s Medical School in 2000 and the following year started her basic surgical training at Epsom and St Helier’s Hospital. In 2005, she finished her PhD in the neurology of the bowel and control of the pelvic floor. Fast forward seven years and, whilst also working fulltime in the NHS specialising in colorectal conditions and pelvic floor issues, Miss Gooneratne completed her higher surgical training. But it wasn’t quite what she had expected. She says, “The idea of working in the NHS is wonderful, but the reality is that I didn’t feel like I was doing what I set out to do, which was to help people. I was fighting fires. I thought I might have to think about another career, and it was hard because all I wanted to do was be a surgeon. Surgery is hardwired into my soul so to leave it was a really big deal.” Miss Gooneratne shares that at the age of 34 she spoke to a career adviser through the British Medical Association and ‘had a lot of therapy’ before making the decision to leave. “As a mum of three, I decided to complete my injectable training during my third maternity leave. It was actually one of my friends who suggested I trained in botulinum toxin. I honestly thought that it was beneath me and had a really negative, pre-conceived idea of aesthetics. I’m hastened to add that I did my training with Cosmetic Courses in 2015 and it was absolutely amazing. Mr Adrian Richards was a real inspiration,” she says. In 2017, she opened The Clinic by Dr Mayoni, which was a finalist for Best New Clinic in 2018’s Aesthetics Awards and received a high commendation at the Awards in 2019. She recognises that her past, both professional and personal, has undoubtably influenced the way she runs her clinic. “My background had a real focus on postpartum women. I was so struck by how devastated they were at what had happened to their bodies through pregnancy and, in turn, what difference I could make to their lives,” she says, adding, “Women still don’t talk about the effects of pregnancy and often they don’t get the right help. Or worse, feel guilty when they do look after themselves. But the truth is that you have to be able to look after yourself before you look after anyone else.” This, Miss Gooneratne explains, is the foundation of her treatment offering which is based around three key pillars: SkinFit, BodyFit and MindFit. She shares, “The sensation of someone looking after you is so powerful.” Linking wellness and aesthetics specifically Miss Gooneratne adds, “How we look is absolutely one aspect of wellness. There is evidence that the hospital anxiety and depression (HADS) score improves by 13% when someone feels good when

they look in the mirror.” She further explains, “If you are looking like the best version of yourself you will undoubtably feel like the best version of yourself. However, there’s such a big disconnect here so it’s our job as aesthetic practitioners to marry the two. In my clinic I also have a functional nutritionist, a personal trainer and a life coach, all of which enables me to do this.” As well as being a key opinion leader for Viveve Medical, AestheticSource and CoolTech, Miss Gooneratne also trains for Cosmetic Courses and Oculo-Facial Aesthetic Academy. She says, “As a trainer, seeing someone else ‘get it’ is an amazing feeling. I thought rather than complaining about the problems in the industry, why not be the one that tries to make a difference and train others. I believe that if people aren’t part of the change, they are part of the problem. Training others is also great learning for my professional development.” When asked about her biggest achievement, Miss Gooneratne was quick to share, “Growing three humans. They are such champions of me and they will grow up to know that there is real value in self-care.”

What was it like to have life coaching? It was fabulous – life coaching meant that I was making decisions from the heart and doing exactly what I wanted to do. I really encourage my team to have it. What treatment is exciting you at moment? I’m particularly excited about the launch of LightStim through AestheticSource and a new skinbetter science AlphaRet Peel being launched later this year. From my experience, one treatment that always delivers is the CoolTech fat freezing, it gives great results and is affordable for patients. What’s the best piece of career advice you’ve been given? Work really hard and be kind. You can’t ever take that away from someone. Who do you admire most in the industry? Consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah, CEO of AestheticSource and nurse Lorna McDonnell Bowes and reconstructive oculoplastic surgeon Mrs Sabrina Shah-Desai are all idols of mine. They were all well-established in something medical before embarking in the aesthetics world and I think that is really important.

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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The Last Word Mr Benji Dhillon explores the differing approaches for consultation remuneration The critical importance of a detailed medically-oriented aesthetic consultation is, I believe, something that virtually everyone in the industry agrees on. It is the true foundation for success, not only for patient treatment outcomes, but also for nurturing a loyal, repeating patient base who trust and value our clinical judgement and expertise. Layered onto this are the evident business benefits of a strongly educational, consultative approach, which ultimately supports good clinic growth and a steady revenue stream. However, the management and monetisation of the consultation process is currently approached in several different ways across the aesthetic industry. Here, I give my opinion on the pros and cons of each approach, along with my personal view on how the importance of the consultation (and the value of practitioner’s time) can be recognised, whilst maintaining an accessible approach for patients, particularly those who are first-time considerers.

accessibility of services at an all-time high. A policy of paid consultations can offer some clinics a type of screening process, ensuring that all patients coming through the door meet a baseline standard of socio-economic status and capability to afford the costs of future treatments. It offers a form of security and revenue protection – patients have already shown some level of commitment and seriousness to their enquiry, having already paid a fee just to get in the door – and the practitioner’s valuable time has at least been covered should the patient decide to proceed no further. In my experience, however, the average patient cannot afford a £100-300 fee for an aesthetic consultation (especially if they are assessing multiple practitioners), but they may well have the means to pay for a larger procedure. However, the clinic won’t secure this revenue potential if the patient is unable (or discouraged) from readily receiving the education and information required to enable them to make that bigger treatment decision.

The paid consultation

The free consultation

Some clinics work on the basis of a paid consultation approach; this asserts that a practitioner’s time is 100% billable and that patients are accessing a service from the start in terms of medical advice and assessment. This is in line with much of the private healthcare market, and indeed was the norm from my own background in surgery, whereby fixed consultation fees of several hundred pounds are expected. However, businesses using this model tend to be aimed at patients considering a treatment whereby the cost of the procedure is usually much higher (often several thousand pounds) and therefore an initial consult fee is deemed acceptable as an entry-level commitment and investment, leading to their desired treatment pathway. For some aesthetic businesses, a fixed consultation fee offers a way to establish kudos, or perceived value for their expertise and standards of service. There is a concern that to offer free consultations may appear ‘cheap’ or will result in practitioners’ time being wasted by too many enquiries, many of which may not convert effectively from the consultation stage to revenue-generating treatments or product purchases. The aesthetics industry is more normalised now than ever, with desire for treatments and

On the other hand, some clinics offer complementary consultations, which opens the business up to a broader pool of potential patients and revenue streams. It can also potentially open a wider circle of word-ofmouth referrals, which may help to offset against any perceived loss of revenue for ‘unconverted’ consultations. Based on my understanding and experience of clinics who use this model, another facet of this approach is the recognition that many patients are not ‘aesthetically aware’ and there is a significant educational role to be played. A substantial proportion of these patients may not even be suitable for treatment in the first place, or would be better served by utilising other healthcare services first before proceeding down the aesthetic route. With this in mind, the complementary consult model asserts that patients shouldn’t be left out of pocket if they turn out to be unsuitable for treatment in the first place. In my experience, this totally open model approach is in the minority in our industry – most clinics hedge their bets with a smaller consultation charge of £25-£50, which is redeemable against treatment or product costs. This helps to ensure some level of commitment from the patient in advance –

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reducing the risk of late cancellations and no shows, which waste the practitioner’s time and can reduce clinic productivity and revenue generation. At Define Clinic, we take a small deposit of £50 upon booking the consultation which is then refunded to the patient when they arrive in the clinic. This helps ensure that practitioner time isn’t wasted, reducing the risk of noshows or late cancellations. A patient may decide following their consultation that they would prefer just to get started with some skincare, or they are perhaps better educated about how to make lifestyle decisions for their own skin health without using our services for the time being. In turn, this positive experience and nonsalesy approach often reaps its own benefits by way of an additional word-of-mouth referral. For me, whilst there may be no immediate revenue generation, these are positive outcomes as it’s what is best for the patient and, ultimately, that is the most important goal that we should be striving to achieve.

Education comes first My personal viewpoint is that it is our duty to educate and to do the right thing for patients, and that this is never a waste of time. The aesthetic industry suffers from some negative public perceptions of taking advantage of people’s vulnerabilities and insecurities – so the more we can do to facilitate an open, honest and consultative approach, the more we will be able to break down stigma and taboos to facilitate access to our industry for a broader group of patients. The bottom line is that time doesn’t necessarily have to be money in aesthetics – it is our privilege to educate and empower our patients, and there are many effective ways we can achieve this through a strong consultation process, without sacrificing clinic revenue or wasting time. Mr Benji Dhillon is the cosmetic director and co-owner of Define Clinic in Beaconsfield. Dr Dhillon trained in plastic surgery and worked for Allergan on its clinical trials, following which he switched to full-time aesthetic practice. He is part of the international faculty for Teoxane.

See Dr Dhillon present at the Teoxane Symposium at ACE 2020 on March 13-14. Register free using code 10101 aestheticsconference.com

Reproduced from Aesthetics | Volume 7/Issue 2 - January 2020


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Over 62% of patients are new to aesthetics – of these, 40% receive further treatments 7

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Includes two safety technologies, CoolControl and Freeze Detect® 6 52 peer-reviewed publications on the science and results of CoolSculpting® as of February 2018 4

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Contact your Allergan representative to find out what CoolSculpting® can do for your business or for more information please visit https://int.coolsculptinghcp.com/uk/ CoolSculpting UK *As of September 2018.

References:

CoolSculpting ® and its design are registered trademarks of Zeltiq Aesthetics, Inc., an Allergan affiliate. Allergan ® and its design are trademarks of Allergan, Inc. © 2019 Allergan. All rights reserved.

1. Manstein D, et al. Lasers Surg Med 2008;40(9):595–604. 2. U.S. Food and Drug Administration: https://www.accessdata.fda.gov/ cdrh_docs/pdf8/K080521.pdf Accessed February 2019. 3. U.S. Food and Drug Administration: https://www.accessdata.fda.gov/ scripts/cdrh/cfdocs/cfpmn/pmn.cfm Accessed February 2019.2. 4. Allergan. Data on file. INT/0071/2018. February 2018. 5. Allergan. INT/0108/2018. 5 Steps to Success. February 2018. 6. Allergan. CoolSculpting ® system user manual. BRZ-101-TUM-EN4-H. December 2016. 7. Stevens WG, et al. Aesth Surg J 2013;33(6):835–46. 8. Allergan. Unpublished data. INT/0484/2018. Number of cycles, systems and accounts to date. October 2018.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

UK/0079/2019 | February 2019

Results and patient experience may vary.

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JANUARY 2020: THE WELLNESS ISSUE  

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